DEPARTMENT OF HEALTH AND SOCIAL SERVICESmanuals.medicaidalaska.com/docs/dnld/Update_02012010... ·...

DEPARTMENT OF HEALTH AND SOCIAL SERVICES

NEW MEDICAID COVERAGE AND PAYMENT

REGULATIONS 7 AAC 105 - 7 AAC 160

All previous Medicaid regulations in 7 AAC 43 have been repealed, except for regulations regarding mental health clinic and substance abuse treatment regulations included at the end of this document.

EFFECTIVE February 1, 2010

Version 14.1

HEALTH AND SOCIAL SERVICES

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TABLE OF CONTENTS

CHAPTER 105. MEDICAID PROVIDER AND RECIPIENT PARTICIPATION. Article 1. Medicaid Program; Scope and Authorization of Service. 100. Covered services 1 110. Noncovered services 2 120. Out-of-state covered services 3 130. Services requiring prior authorization 3 Article 2. Provider Enrollment, Rights, and Responsibilities. 200. Eligible Medicaid providers 6 210. Provider enrollment requirements 8 220. Provider responsibilities 9 230. Requirements for provider records 10 240. Request for records 11 250. Payment from other sources 11 260. Recouping an overpayment 11 270. First-level provider appeal 13 280. Second-level provider appeal 14 290. Reports requested by the department 16 Article 3. Provider Sanctions and Remedies. 400. Grounds for sanctioning providers 16 410. Sanctions 18 420. Imposition of sanction 19 430. Scope of sanction 20 440. Notice of sanction 20 450. Provider education 21 460. Appeal of sanction 21 470. Restrictions on payments 22 480. Withholding of payments 23 490. Definitions 23 Article 4. Restriction of Recipient's Choice of Providers; Cost-Sharing. 600. Restriction of recipient’s choice of providers 24 610. Recipient cost-sharing 25 CHAPTER 110. MEDICAID COVERAGE; PROFESSIONAL SERVICES. Article 1. Advanced Nurse Practitioner Services. 100. Advanced nurse practitioner enrollment requirements 27 105. Advanced nurse practitioner services 28 Article 2. Chiropractic Services. 120. Chiropractic coverage and limitations 28 Article 3. Dental Services. 140. Dental provider enrollment requirements 29


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145. Dental services for adults 30 150. Dental services for recipients under 21 years of age 32 155. Dentist-administered anesthesia and sedation 33 160. Diagnostic x-ray 33 Article 4. Direct-Entry Midwife Services. 180. Direct-entry midwife coverage and limitations 34 Article 5. EPSDT Services. 200. Purpose of EPSDT services 34 205. EPSDT screening services 34 210. EPSDT covered services 36 Article 6. Family Planning Services. 230. Family planning services 37 Article 7. Imaging Services. 240. Imaging services 38 Article 8. Nurse Anesthetist Services. 250. Registered nurse anesthetist enrollment and services 38 Article 9. Nutrition Services. 270. Nutrition services provider enrollment requirements 39 275. Nutrition services for recipients under 21 years of age 39 280. Nutrition services for pregnant women 40 Article 10. Physician Services. 400. Physician services provider enrollment requirements 41 405. Physician services coverage and limitations 42 410. Physician services in a nursing facility 43 415. Sterilization by a physician 43 420. Hysterectomy by a physician 44 425. Obstetrical care by a physician 44 430. Office medical supplies 44 435. Physician laboratory services 44 440. Physician radiology and imaging services 45 445. Mental health services by a physician 45 450. Surgical assistant 46 455. Physician assistant enrollment and services 46 Article 11. Podiatry Services. 500. Podiatry services provider enrollment requirements 47 505. Podiatry services 48 Article 12. Private-Duty Nursing Services. 520. Private-duty nursing agency enrollment requirements 48 525. Private-duty nursing services; covered and noncovered services 49 530. Private-duty nursing services; prior authorization 50 Article 13. Psychologist Services. 550. Psychologist services 51 Article 14. Targeted Case Management. 600. Targeted case management for children with disabilities 52 Article 15. Telemedicine Services. 620. Scope 54


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625. Telemedicine applications; limitations 54 630. Conditions for payment 55 635. Exclusions 55 639. Definitions 56 Article 16. Vision Care Services. 700. Vision care provider enrollment requirements 56 705. Vision care services 57 710. Complete vision examination 57 715. Noncovered vision care services 58 CHAPTER 115. MEDICAID COVERAGE; THERAPIES AND RELATED SERVICES. Article 1. Occupational Therapy Services. 100. Occupational therapy provider enrollment requirements 59 110. Occupational therapy services 60 120. Occupational therapy evaluation and treatment plan 60 Article 2. Outpatient Therapy Center Services. 200. Outpatient therapy center enrollment requirements 61 210. Outpatient therapy center services 61 220. Outpatient therapy center evaluation and treatment plan 62 Article 3. Physical Therapy Services. 300. Physical therapy provider enrollment requirements 63 310. Physical therapy services 64 320. Physical therapy evaluation and treatment plan 64 Article 4. Speech-Language Pathology Services. 400. Speech-language pathology enrollment requirements 65 410. Speech-language pathology services 66 420. Speech-language evaluation and treatment plan 67 Article 5. Hearing Services. 500. Hearing services provider enrollment 68 510. Audiologist services 69 520. Hearing aid dealer services 69 530. Hearing services and items 69 540. Prior authorization of hearing services and items 73 549. Definitions 74 Article 6. School-Based Services. 600. School-based services 75 CHAPTER 120. MEDICAID COVERAGE; PRESCRIPTION DRUGS AND MEDICAL SUPPLIES; DURABLE MEDICAL EQUIPMENT; TRANSPORTATION SERVICES. Article 1. Prescription Drugs and Medical Supplies. 100. Provider requirements 78 110. Drug coverage 79 120. Drug use review 82


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130. Prior authorization and limitations on prescribed drugs 84 140. Preferred drug list 84 Article 2. Durable Medical Equipment and Medical Supplies; Related Services. 200. Enrollment; general provisions; covered items and services 85 205. Noncovered items and services 89 210. Prior authorization 90 215. Purchase of items 92 220. Replacement of items 92 225. Rental of items; general provisions 93 230. Rental of items; changes during rental periods 93 235. Respiratory therapy equipment, supplies, and assessment visits 94 240. Enteral and oral nutritional products 95 245. Home infusion therapy 96 299. Definitions 97 Article 3. Transportation and Accommodation Services. 400. Transportation provider enrollment 98 405. Transportation and accommodation covered services 98 410. Prior authorization for nonemergency transportation services 99 415. Emergency transportation services 100 420. Air ambulance services 101 425. Accommodation services 101 430. Authorized escort 101 435. Prematernal home services 102 440. Mortuary expenditure 102 445. Contracted transportation and accommodation services 102 490. Definitions 103 CHAPTER 125. MEDICAID COVERAGE; PERSONAL CARE SERVICES AND HOME HEALTH SERVICES Article 1. Personal Care Services. 10. Purpose and scope of personal care services 104 20. Personal care assessment tool (PCAT) 105 30. Personal care covered services 107 40. Personal care excluded services 109 50. Personal care place of service 110 60. Personal care provider certification and enrollment 111 80. Personal care provider decertification and disenrollment 111 90. Employment of personal care assistants; qualifications 112 100. Safety of recipients 113 110. Consumer-directed and agency-based personal care programs; safety of employees; termination of service 113 120. Responsibilities of personal care assistant 114 130. Consumer-directed personal care program; personal care agencies 115 140. Consumer-directed personal care program; recipient requirements 116 150. Agency-based personal care program; personal care agencies 117 160. Agency-based personal care program; personal care assistant


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education and training requirements 117 170. Agency-based personal care program; supervising registered nurse 119 180. Review and appeal rights 120 190. Consumer-directed and agency-based personal care programs; compliance reviews 120 195. Payment for personal care services 120 199. Definitions 121 Article 2. Home Health Care Services. 300. Home health care provider enrollment 122 310. Home health care services 122 320. Requirements for home health care services 123 339. Definitions 125 CHAPTER 130. MEDICAID COVERAGE; HOME AND COMMUNITY-BASED WAIVER SERVICES Article 1. Home and Community-Based Waiver Services; Residential Psychiatric Treatment Center Level of Care. 100. Purpose 126 105. Recipient eligibility 126 110. Recipient enrollment and disenrollment for FASD/SED waiver services 128 115. FASD/SED waiver services 129 120. FASD/SED waiver plan-of-care standards 130 125. Provider endorsement 131 130. Plan-of-care development and coordination services 132 135. Professional and paraprofessional training and consultation services 133 140. Treatment and intervention mentor services 134 145. FASD/SED day habilitation services 135 150. FASD/SED residential habilitation services 135 155. Community transition services 136 160. Supported-employment development services; supported-employment ongoing services 137 165. FASD/SED respite care services 138 199. Definitions 139 Article 2. Home and Community-Based Waiver Services; Nursing Facility and ICF/MR Level of Care. 200. Purpose 140 202. Services provided by family members 141 205. Recipient enrollment and eligibility 141 210. Recipient disenrollment 143 220. Provider certification and enrollment 143 225. Provider disenrollment and decertification 145 230. Screening, assessment, plan of care, and level-of-care determination 145 235. Nursing oversight 147 240. Care coordination services 148 245. Chore services 150 250. Adult day services 151


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255. Residential supported-living services 151 260. Day habilitation services 152 265. Residential habilitation services 153 270. Supported-employment services 154 275. Intensive active treatment services 155 280. Respite care services 156 285. Specialized private-duty nursing services 158 290. Transportation services 159 295. Meals services 159 300. Environmental modification services 160 305. Specialized medical equipment and supplies 162 310. Restrictions on residential supported-living services payment 163 319. Definitions 164 CHAPTER 140. MEDICAID COVERAGE; FACILITY AND FACILITY-BASED SERVICES Article 1. Ambulatory Surgical Center Services. 100. Ambulatory surgical center enrollment requirements 166 105. Ambulatory surgical center services 166 110. Ambulatory surgical center reports 167 Article 2. Health Clinic Services; Federally Qualified Health Centers and Rural

Health Clinics. 200. Health clinic enrollment and reporting 167 205. Federally qualified health centers 169 210. Rural health clinics 170 215. Health clinic services and payment conditions 170 220. Health clinic services provided off-site 171 229. Definitions 172 Article 3. Hospice Care Services. 270. Hospice care provider enrollment 173 275. Hospice care services 173 280. Hospice care for individuals under 21 years of age 175 289. Definitions 176 Article 4. Hospital Services. 300. Hospital provider requirements 176 305. Admission to a hospital 177 310. Covered hospital services 177 315. Noncovered hospital services 177 320. Length of hospitalization 180 325. Billing for hospital services 180 Article 5. Inpatient Psychiatric Hospital Services. 350. Inpatient psychiatric hospital provider requirements 180 355. Inpatient psychiatric hospital services 181 360. Inpatient psychiatric hospital admission 181 365. Inpatient psychiatric plan of care 183


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Article 6. Residential Psychiatric Treatment Center (RPTC) Services. 400. Residential psychiatric treatment center provider requirements 184 405. Residential psychiatric treatment center admission 185 410. Residential psychiatric treatment center plan of care 186 415. Residential psychiatric treatment center services 187 Article 7. Nursing Facility Services: ICF and SNF. 500. Nursing facility enrollment and conditions for payment 188 505. Authorization for admission and determination of level of care 189 510. Intermediate care facility services 189 515. Skilled nursing facility services 190 520. Care plan counseling 191 525. Transfer from hospital care to nursing facility care 191 530. Transfer from nonacute care to nursing facility care 192 535. Continuing placement in a nursing facility 193 540. Transfer of recipients 193 545. Discharge of recipients 194 550. Third-party resources 194 555. Days chargeable 195 560. Payment during impending decertification 195 565. Payment for nursing facility transfers 195 570. Other payments 195 575. Recipient personal funds and personal property 195 580. Required all-inclusive services 197 585. Absence from nursing facility 197 590. Medicare coinsurance 198 595. Definitions 198 Article 8. Intermediate Care Facility for the Mentally Retarded Services. 600. ICF/MR enrollment and conditions for payment 199 605. ICF/MR interdisciplinary teams 201 610. Records, habilitative plan of care, treatment, and reevaluation 201 615. Required all-inclusive services 203 620. Absence from an ICF/MR 203 625. Transfer of recipients 204 630. Discharge of recipients 204 635. Applicability of other sections 204 640. Qualified mental retardation professionals 204 CHAPTER 145. MEDICAID PAYMENT RATES. Article 1. Medicaid Payment; Conditions and Methods. 05. Conditions for payment 205 10. Prohibition against reassignment 206 15. Payment reduced by cost-sharing 207 20. Methodology used to establish provider payment rates 207 25. Payment for services provided out of state 207 Article 2. RBRVS Methodology. 50. Resource-based relative value scale rate-setting methodology 208


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Article 3. Payment Rates; Professional Services. 100. Advanced nurse practitioner services payment rates 210 110. Chiropractic services payment rates 211 120. Dental services payment rates 211 130. Direct-entry midwife services payment rates 211 140. Payment for EPSDT services 211 150. Family planning services payment rates 212 160. Imaging services payment rates 212 170. Nurse anesthetist payment rates 212 180. Nutrition services payment rates 212 200. Physician services payment rates 212 220. Physician surgical procedures payment rates 213 240. Podiatry services payment rates 214 250. Private-duty nursing rates 214 260. Psychologist services payment rates 214 265. Targeted case management payment rates 215 270. Telemedicine payment rates 216 280. Vision examinations and services payment rates 216 Article 4. Payment Rates; Therapies and Related Services. 300. Occupational therapy services payment rates 217 310. Outpatient therapy center payment rates 217 320. Physical therapy services payment rates 217 330. Speech-language pathology services payment rates 217 340. Hearing services payment rates 217 350. School-based services payment rates 219 Article 5. Payment Rates; Prescription Drugs and Medical Supplies; Durable Medical Equipment; Transportation; Laboratory Services. 400. Prescription drug payment rate 219 410. Dispensing fee 220 420. Durable medical equipment, supplies, and respiratory therapy payment rates 222 440. Transportation and accommodation services payment rates 224 460. Laboratory services payment 224 Article 6. Payment Rates; Personal Care and Home Health Care. 500. Personal care services payment rates 225 510. Home health care services payment rate 225 Article 7. Payment Rates; Home and Community-Based Waiver Services. 520. Home and community-based waiver services; nursing facility and ICF/MR level-of-care payment rates 225 530. Home and community-based waiver services; nursing facility and ICF/MR level-of-care determination of administrative and general cost rates 229 540. Home and community-based waiver services; residential psychiatric treatment center level-of-care payment rates 231 Article 8. Payment Rates; Behavioral Health Services. 580. Behavioral health services payment rates 232


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Article 9. Payment Rates; Facility and Facility-Based Services. 600. Hospital payment rates 233 610. Inpatient psychiatric hospital payment rates 234 620. Residential psychiatric treatment center payment rates 234 630. Ambulatory surgical center payment rates 235 640. Nursing facility payment rates 235 650. ICF and SNF all-inclusive rates 236 660. ICF/MR all-inclusive rate 237 670. Recipient cost-of-care contribution 237 690. Hospice care payment rates 238 Article 10: Payment Rates; Rural Health Clinic and Federally Qualified Health Center Services. 700. Health clinic payment rates 239 710. Calculating total health clinic visits 242 720. Health clinic re-basing 244 730. Health clinic exceptional relief 244 739. Definitions 244 CHAPTER 150. PROSPECTIVE PAYMENT SYSTEM; OTHER PAYMENT. 10. Purpose of prospective payment system 246 20. Applicability of prospective payment system 246 30. Establishment of prospective rates 246 40. Prospective rates defined 247 100. Methodology and criteria for proportionate share payments to publicly owned or operated hospitals 247 110. Methodology and criteria for proportionate share payments to privately owned or operated hospitals 250 120. Methodology and criteria for proportionate share payments to state-owned or state-operated hospitals 254 130. Establishment of uniform accounting, budgeting, and financial reporting 255 140. Processing of annual year-end report 256 150. Adjustment factors 257 160. Methodology and criteria for approval or modification of a payment rate 257 170. Allowable reasonable operating costs 262 180. Methodology and criteria for additional payments as a disproportionate share hospital 265 190. Optional payment rate methodology and criteria for small facilities 276 200. Facility audits and desk reviews 279 210. Procedure for establishment of rates 283 220. Administrative appeal 283 230. Appeal procedures 284 240. Exceptional relief to prospective payment rate setting 286 990. Definitions 288


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CHAPTER 155. TRIBAL HEALTH PROGRAMS. 10. Tribal health program payment methodology 292 20. Community health aides and practitioners 292 CHAPTER 160. MEDICAID PROGRAM; GENERAL PROVISIONS. Article 1. Program Integrity and Quality Assurance. 100. Program integrity 293 110. Fiscal audit 293 120. Use of statistical sampling 295 130. Appeal 295 140. Quality assurance program 295 Article 2. Third-Party Liability; Estate Recovery. 200. Third-party resources 297 210. Estate Recovery 298 220. Liens 298 230. Appealing a lien 299 240. Waiving estate recovery 300 250. Exemptions from estate recovery 300 Article 3. General Provisions. 900. Requirements adoption by reference 302 990. Definitions 308 CHAPTER 43. BEHAVIORAL HEALTH SECTIONS Article 6. Children's Services. 470. Children's mental health services. 315 471. Severely emotionally disturbed children. 318 Article 7. Mental Health Services. 472. Family skill development services. 319 474. Group skill development services. 319 476. Day treatment services. 320 478. Recipient support services. 321 481. Behavioral rehabilitation services 321 Article 8. Authorization of Mental Health Rehabilitation Services. 484. Prior authorization of mental health rehabilitation services. 322 486. Medical necessity determinations for mental health rehabilitation services. 323 488. Extension of service limitations in exceptional circumstances. 324 Article 15. Mental Health Clinic Services. 725. Conditions for payment. 325 726. Coverage for mental health clinic services. 327 727. Service limitations. 328 728. Clinical records, treatment plans, and assessments. 329


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Article 16. Rates for Mental Health Services. 729. Rates. 332 Article 17. Mental Health Rehabilitation Services. 734. Mental health rehabilitation services. 334 735. Functional assessment. 336 736. Individual skill development services. 337 737. Case management. 337 738. Crisis intervention. 337 739. Medication administration services. 338 Article 18. Substance Abuse Rehabilitative Services. 740. Substance abuse rehabilitative services. 339 741. Assessment and diagnosis services. 340 742. Outpatient services. 341 743. Intensive outpatient services. 341 744. Intermediate services. 341 745. Medical services. 342 746. Limitations and payments for services. 342 Article 34. Definitions. 1990. Definitions 344

Register 193, April 2010 HEALTH AND SOCIAL SERVICES

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Part 8. Medicaid Coverage and Payment. Chapter 105. Medicaid Provider and Recipient Participation (7 AAC 105.100 - 7 AAC 105.610) 110. Medicaid Coverage; Professional Services (7 AAC 110.100 - 7 AAC 110.715) 115. Medicaid Coverage; Therapies and Related Services (7 AAC 115.100 - 7 AAC 115.600) 120. Medicaid Coverage; Prescription Drugs and Medical Supplies; Durable Medical Equipment; Transportation Services (7 AAC 120.100 - 7 AAC 120.490) 125. Medicaid Coverage; Personal Care Services and Home Health Care Services (7 AAC 125.010 - 7 AAC 125.399) 130. Medicaid Coverage; Home and Community-Based Waiver Services (7 AAC 130.100 - 7 AAC 130.319) 140. Medicaid Coverage; Facility and Facility-Based Services (7 AAC 140.100 - 7 AAC 140.640) 145. Medicaid Payment Rates (7 AAC 145.005 - 7 AAC 145.739) 150. Prospective Payment System; Other Payment (7 AAC 150.010 - 7 AAC 150.990) 155. Tribal Health Programs (7 AAC 155.010 - 7 AAC 155.020) 160. Medicaid Program; General Provisions (7 AAC 160.100 - 7 AAC 160.990)

Chapter 105. Medicaid Provider and Recipient Participation. Article 1. Medicaid Program; Scope and Authorization of Service (7 AAC 105.100 - 7 AAC

105.130) 2. Provider Enrollment, Rights, and Responsibilities (7 AAC 105.200 - 7 AAC 105.290) 3. Provider Sanctions and Remedies (7 AAC 105.400 - 7 AAC 105.490) 4. Restriction of Recipient's Choice of Providers; Cost-Sharing (7 AAC 105.600 -

7 AAC 105.610)

Article 1. Medicaid Program; Scope and Authorization of Service. Section 100. Covered services 110. Noncovered services 120. Out-of-state covered services 130. Services requiring prior authorization 7 AAC 105.100. Covered services. The department will pay for a service only if that service (1) is identified as a covered service in accordance with AS 47.07, 7 AAC 43, and 7 AAC 105 - 7 AAC 160; (2) is provided to an individual who is eligible for Medicaid under 7 AAC 100 on the date of service; (3) is ordered or prescribed by a provider authorized to order or prescribe that service under applicable law; (4) is provided by a person who is enrolled as a Medicaid provider or rendering provider under 7 AAC 105.210, or otherwise eligible to receive payment for


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services under 7 AAC 43 and 7 AAC 105 - 7 AAC 160; (5) is medically necessary as determined by criteria established under 7 AAC 43 and 7 AAC 105 - 7 AAC 160 or by the standards of practice applicable to the provider; (6) has received prior authorization from the department, if prior authorization is required under 7 AAC 43 or 7 AAC 105 - 7 AAC 160; and (7) is not specifically excluded as a noncovered service under 7 AAC 43 or 7 AAC 105 - 7 AAC 160. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 105.110. Noncovered services. Unless otherwise provided in 7 AAC 43 or 7 AAC 105 - 7 AAC 160, the department will not pay for a service that is (1) not reasonably necessary for the diagnosis and treatment of an illness or injury, or for the correction of an organic system, as determined upon review by the department; (2) not properly prescribed or medically necessary in accordance with criteria established under 7 AAC 43 and 7 AAC 105 - 7 AAC 160 or by standards of practice applicable to the prescribing provider; (3) incurred for an evaluative or periodic checkup, examination, or immunization

(A) that is in connection with the participation, enrollment, attendance, or accomplishment of a program or activity unrelated to the recipient’s physical or mental health or rehabilitation; or (B) unless it is

(i) for a mammogram; (ii) part of an EPSDT screening; or (iii) required by the department for the purpose of determining eligibility for Medicaid;

(4) for or in connection with cosmetic therapy or plastic or cosmetic surgery, including rhinoplasty, nasal reconstruction, excision of keloids, augmentation mammoplasty, silicone or silastic implants, facioplasty, osteoplasty (prognathism and micronathism), dermabrasion, skin grafts, and lipectomy; however, coverage is available if required for the following corrective actions if performed within the normal course of treatment or otherwise beginning no later than one year after birth or the event that caused the need for the corrective action:

(A) repair of an injury; (B) improvement of the functioning of a malformed body member; (C) correction of a visible disfigurement that would materially affect the recipient’s acceptance in society;

(5) a nonmedical charge imposed by a recipient’s friend or relative; (6) for a person who is in the custody of federal, state, or local law enforcement, including a juvenile in a detention facility; (7) for an experimental or investigational service, including one

(A) that is in a phase I or II clinical trial as defined in the United States Department of Health and Human Services, National Institutes of Health,


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Glossary of Terms for Human Subjects Protection and Inclusion Issues, adopted by reference in 7 AAC 160.900; (B) for which inadequate available clinical or preclinical data exists to provide a reasonable expectation that the proposed service is at least as safe and effective as one not under experiment or investigation; (C) for which an expert has issued an opinion that additional information is needed to assess the safety or efficacy of the proposed service; (D) for which final approval from the appropriate governmental body has not been granted for the specific indications for which the use of the service is being proposed; however, if a drug has received final approval from the United States Food and Drug Administration (FDA) for any indication, final approval is not required for the specific indication for which use is being proposed if

(i) the prescription or order was issued by a licensed health care provider within the scope of the provider’s license; (ii) prior authorization was obtained from the department if required under 7 AAC 43 or 7 AAC 105 - 7 AAC 160; or (iii) the condition being treated with the drug is not otherwise excluded as a use of the drug; or

(E) whose use is not in accordance with customary standards of medical practice;

(8) for missed appointments; however, the provider may charge the recipient; (9) for interpreter services; (10) for infertility services; (11) for impotence therapy and services; (12) for treatment, therapy, surgery, or other procedures related to gender reassignment; (13) for sterilization for recipients under 21 years of age and hysterectomies performed solely for sterilization purposes; (14) for nonsurgical weight reduction or maintenance treatment programs and products; (15) for nonmedical fitness maintenance centers and services; (16) for educational services or supplies that are separately identifiable in

(A) the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services’ (CMS) Healthcare Common Procedure Coding System (HCPCS), adopted by reference in 7 AAC 160.900; or (B) Alternative Link’s ABC Coding Manual for Integrative Healthcare, adopted by reference in 7 AAC 160.900;

(17) an alternative therapy or other service including acupuncture, homeopathic or naturopathic remedy, or Ayurvedic medicine; (18) an outpatient drug for which payment under the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services’ drug rebate program established in 42 U.S.C. 1396r-8 is not available; or (19) for which the recipient does not meet the eligibility requirements for that service under 7 AAC 100. (Eff. 2/1/2010, Register 193)


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Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 105.120. Out-of-state covered services. (a) Unless otherwise provided in 7 AAC 43 or 7 AAC 105 - 7 AAC 160, the department will cover a service provided out of state to the same extent it would cover the service provided in this state if (1) the service is provided to a recipient who is a resident of this state; and (2) the department is able to verify one of the following situations:

(A) the recipient requires a medical service that is not available in this state or the provision of that service out of state is more cost-effective; (B) the medical service is needed due to a medical emergency while a recipient is out of state and the recipient’s health would be endangered if the recipient were required to travel to this state for the needed medical service; (C) laboratory specimens are sent out of state because

(i) the laboratory service is not offered in this state; (ii) the laboratory service is more readily available out of state; or (iii) to have the laboratory work performed out of state is more cost-effective.

(b) The department may pay an out-of-state provider for a service provided to a recipient from this state that meets the requirements of (a) of this section if the provider (1) is enrolled in the Medicaid program in this state; (2) is enrolled in the Medicaid program in the jurisdiction where the service is provided; and (3) possesses the appropriate license in the other jurisdiction to provide the required service. (c) The department may deny a request for a service provided out of state that requires prior authorization by the department if the requirements of (a) of this section are not met. (d) An inpatient psychiatric hospital, psychiatric facility, and a residential psychiatric treatment center may be approved by the department as a provider, if the department determines that a need exists for the service under (a)(2) of this section. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.032 AS 47.07.040 AS 47.07.030 7 AAC 105.130. Services requiring prior authorization. (a) Except as otherwise provided in 7 AAC 43 and 7 AAC 105 - 7 AAC 160, the department will not pay for the following services unless the department has given prior authorization for the service: (1) nonemergency, medically necessary transportation and accommodation services; (2) a specific health care service for which prior authorization is specifically required under 7 AAC 43 or 7 AAC 105 - 7 AAC 160; (3) a service that exceeds an annual or periodic service limitation established in 7 AAC 43 or 7 AAC 105 - 7 AAC 160; (4) an item of durable medical equipment, supplies, or hearing items


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identified in 7 AAC 43 or 7 AAC 105 - 7 AAC 160 as requiring prior authorization; (5) respiratory therapy; (6) home health care services under 7 AAC 125.300 - 7 AAC 125.399; (7) home infusion therapy services; (8) private-duty nursing services; (9) hospice care services; (10) outpatient magnetic resonance imaging, positron emission tomography, and emission computerized tomography scans; (11) an inpatient or outpatient procedure or diagnosis, regardless of the length of stay, identified in the English description of diagnoses and procedures in the Select Diagnoses and Procedures Pre-certification List, adopted by reference in 7 AAC 160.900; (12) an inpatient hospital continued stay that exceeds an applicable limitation in 7 AAC 140.320 on length of hospitalization; (13) a prescription drug identified on the Alaska Medicaid Prior-authorized Medications List, adopted by reference in 7 AAC 160.900; (14) an inpatient psychiatric hospital admission in accordance with 7 AAC 140.360; (15) a residential psychiatric treatment center admission or continued stay in accordance with 7 AAC 140.405; (16) an administrative-wait or swing-bed stay at a general acute care hospital; (17) a long-term care facility admission or continued stay; (18) home and community-based waiver services under 7 AAC 130; (19) personal care services under 7 AAC 125.010 - 7 AAC 125.199. (b) Except as provided in 7 AAC 140.320, failure to obtain the required prior authorization may result in nonpayment, regardless of the eligibility of the recipient or the appropriateness of the services. (c) For prior authorization, factors that the department will consider include the service's medical necessity, clinical effectiveness, cost-effectiveness, and likelihood of adverse effects, as well as service-specific requirements in 7 AAC 43 or 7 AAC 105 - 7 AAC 160. The department may place minimum or maximum quantities allowed of a specific service, may require other services before the recipient receives the requested service, or may require prior authorization for other services, as necessary (1) for the protection of the public health, safety, and welfare; (2) to prevent waste, fraud, and abuse of the Medicaid program; or (3) to maintain the financial integrity of the department and the Medicaid program. (d) The department may pay for a service under (a) of this section without prior authorization if prior authorization was not possible before the service was provided or a claim for payment is being processed after the service was provided following determination of a recipient’s retroactive eligibility under 7 AAC 100.072. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040


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Article 2. Provider Enrollment, Rights, and Responsibilities. Section 200. Eligible Medicaid providers 210. Provider enrollment requirements 220. Provider responsibilities 230. Requirements for provider records 240. Request for records 250. Payment from other sources 260. Recouping an overpayment 270. First-level provider appeal 280. Second-level provider appeal 290. Reports requested by the department 7 AAC 105.200. Eligible Medicaid providers. (a) Subject to all other requirements of 7 AAC 43 and 7 AAC 105 - 7 AAC 160, the following types of providers are eligible to enroll with the department and bill directly for services rendered: (1) a person with an active license under AS 08, or under the laws of the jurisdiction in which the person provides services, to practice as

(A) a physician, including an osteopath; (B) a podiatrist; (C) a dentist; (D) an optometrist; (E) a chiropractor; (F) a pharmacist or retail pharmacy; (G) a physical therapist; (H) an occupational therapist; (I) an audiologist; (J) a speech-language pathologist; (K) an advanced nurse practitioner; (L) a direct-entry midwife; (M) a dietitian; (N) a nutritionist; (O) a psychologist (P) a hearing aid dealer; or (Q) a registered nurse anesthetist;

(2) a facility licensed under AS 47.32, or under the laws of the jurisdiction in which it provides services, to operate as

(A) a general acute care hospital or inpatient psychiatric hospital; (B) a long-term care facility; (C) a home health agency; (D) a rural health clinic; (E) an ambulatory surgical center; (F) a hospice care agency; (G) a residential psychiatric treatment center for persons under 22 years of age; or (H) an intermediate care facility for the mentally retarded


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(ICF/MR); (3) a company or individual not excluded in (b) of this section, supplying

(A) medical transportation, ambulance services, oxygen, or eyeglasses; (B) under 7 AAC 120.200 - 7 AAC 120.299, durable medical equipment, medical supplies, prosthetics, orthotics, noncustomized-fabricated orthotics, respiratory therapy, enteral and oral nutritional products, or home infusion therapy; or (C) items paid under 7 AAC 130.305 as specialized medical equipment and supplies;

(4) a provider of EPSDT screening services under 7 AAC 110.205; (5) a facility providing services for end-stage renal disease; (6) a personal care agency; (7) a home and community-based waiver services provider, including a provider of environmental modification services under 7 AAC 130.300; (8) a care coordination agency provider, as defined in 7 AAC 130.319; (9) a residential supported-living services provider, as defined in 7 AAC 130.319; (10) a federally qualified health center (FQHC); (11) a tribal health program; (12) a provider of in-state freestanding or portable x-ray services; (13) a provider of behavioral rehabilitation services for severely emotionally disturbed children; (14) a private-duty nursing agency; (15) a school district providing a Medicaid-covered service to a Medicaid recipient; (16) an independent laboratory; (17) an outpatient therapy center; (18) a provider of family planning services; (19) a provider of targeted case management services; (20) a community mental health clinic; (21) a mental health physician clinic, as defined in 7 AAC 43.1990; (22) a substance abuse rehabilitative services provider under 7 AAC 43.740 - 7 AAC 43.746. (b) Each of the following providers must enroll with the department as a rendering provider, but payment for those services will be made through the rendering provider’s supervising health care provider enrolled under this section: (1) a licensed physician assistant; (2) a licensed physical therapy assistant; (3) a licensed occupational therapy assistant; (4) a registered speech-language pathologist assistant; (5) a registered respiratory therapist; (6) a certified respiratory therapy technician; (7) a personal care assistant; (8) a care coordinator; (9) a licensed practical nurse who provides direct services to a recipient as


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an employee of a private-duty nursing agency; (10) a licensed registered nurse who provides direct services to a recipient as an employee of a private-duty nursing agency. (c) Notwithstanding any other provision of 7 AAC 43 or 7 AAC 105 - 7 AAC 160, and if the employee has an active license from a jurisdiction in the United States, a health care provider who is an employee of the federal government assigned to a tribal health program is exempt from any requirement in 7 AAC 43 or 7 AAC 105 - 7 AAC 160 that the provider be licensed, certified, or registered by this state to be eligible under this section. (d) Notwithstanding any other provision of 7 AAC 43 or 7 AAC 105 - 7 AAC 160, a hospital, clinic, or other type of health care facility that is operated by a tribal health program is exempt from a requirement in 7 AAC 43 or 7 AAC 105 - 7 AAC 160 that the provider be licensed or certified by this state to be eligible under this section. (e) If a rendering provider identified in (b) of this section is an employee of or under contract with an enrolled tribal health program, that tribal health program is the supervising health care provider of that rendering provider for the purposes of receiving payment under 7 AAC 43 or 7 AAC 105 - 7 AAC 160. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 105.210. Provider enrollment requirements. (a) An eligible provider shall enroll with the department before billing the department for payment of services covered under 7 AAC 43 or 7 AAC 105 - 7 AAC 160 that are provided to recipients. (b) To be enrolled in this state, a provider (1) must submit a completed provider enrollment form and provider information submission agreement on forms provided by the department; (2) must verify that the provider meets all other applicable requirements of 7 AAC 43 and 7 AAC 105 - 7 AAC 160 and all applicable federal and state licensing and certification requirements; (3) must comply with all federal and state laws as they apply to providing health care or related services to Medicaid recipients in this state, including laws related to recipient confidentiality, electronic transactions, and civil rights; (4) must assume responsibility for all information and claims submitted to the department by that provider or that provider’s billing agent; (5) must agree to submit claims in the form or format required by the department for claim submission; (6) must comply with the requirements of AS 47.05.300 - 47.05.390 and 7 AAC 10.900 - 7 AAC 10.990 (barrier crimes, criminal history checks, and centralized registry), if applicable to that provider type; and (7) if an out-of-state provider, must

(A) verify enrollment in the Medicaid program in the jurisdiction in which services are provided if Medicaid enrollment is available for that type of provider in that jurisdiction; or (B) provide documentation from the jurisdiction in which the provider provides services that Medicaid enrollment is not available in the jurisdiction for that type of provider.

(c) A provider who is practicing under a temporary or locum tenens permit,


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license, or authorization issued under AS 08, and who is substituting for another provider, being evaluated for permanent employment, or temporarily employed by a facility while it attempts to fill a vacant position must enroll as required in (a) and (b) of this section. (d) The department may disenroll a provider who has not submitted a claim for at least 18 months. (e) The department may enroll a provider with a retroactive effective date of enrollment of up to one year if the provider (1) meets the requirements of this section; and (2) provided services covered under 7 AAC 43 or 7 AAC 105 - 7 AAC 160 to a Medicaid recipient during the immediately preceding year for which the provider has not been paid. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 AS 47.05.300 Editor’s note: A copy of the Department of Health and Social Services’ provider enrollment form and provider information submission agreement may be obtained from the department’s designee, Affiliated Computer Services, Inc., by telephone at 800-770-5650 (within Alaska but outside Anchorage) or 907-644-6800. The form may be obtained at the Affiliated Computer Services, Inc. website at http://www.medicaidalaska.com or by mail from the following address: Affiliated Computer Services, Inc., Provider Enrollment, P.O. Box 240808, Anchorage, AK 99524-0808. 7 AAC 105.220. Provider responsibilities. (a) Providing medical or medically related services to recipients or billing the department for those services constitutes agreement by the provider to (1) comply with all applicable federal and state laws related to providing medical or medically related services to Medicaid recipients in this state, including laws related to recipient confidentiality, electronic transactions, and civil rights; and (2) submit claims in the form or format required by the department for claim submission; and (3) cooperate in reports, surveys, reviews, or audits conducted by the department. (b) A provider shall retain records necessary to disclose fully to the department the extent of services provided to recipients. Information regarding a payment must be made available, upon request, to state and federal personnel of agencies associated with the Medicaid program. (c) A provider shall allow on-site inspection by authorized representatives of both state and federal agencies associated with the Medicaid program. (d) A provider is responsible for claims submitted or certified by an authorized representative. (e) A provider’s or agent’s endorsement of a check received from the department certifies that the claim for which the check is payment is true and accurate unless written notice of an error is sent by the provider to the department no more than 30 days after the date that the check is negotiated. (f) In accordance with 7 AAC 105.400, a provider must refund to the department any paid claim that the department finds, after post-payment review under 7 AAC 160.100 - 7 AAC 160.140, does not meet the requirements of 7 AAC 43 or 7 AAC 105 - 7 AAC 160. (Eff. 2/1/2010, Register 193)


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Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 105.230. Requirements for provider records. (a) A provider shall maintain accurate financial, clinical, and other records necessary to support the services for which the provider requests payment. The provider shall ensure that the provider’s staff, billing agent, or other entity responsible for the maintenance of the provider’s financial, clinical, and other records meets the requirements of this section. (b) A provider’s record must identify recipient information for each recipient including the (1) name of the recipient receiving treatment; (2) specific services provided; (3) extent of each service provided; (4) date on which each service was provided; and (5) individual who provided each service. (c) A provider’s record must identify financial information for each recipient including (1) the charge for each service provided; (2) each payment source pursued; (3) the date and amount of all debit and credit billing actions for each date of service provided; and (4) the amounts billed and paid. (d) A provider shall maintain a clinical record, including a record of therapeutic services, in accordance with professional standards applicable to the provider, for each recipient. The clinical record must include (1) information that identifies the recipient’s diagnosis; (2) information that identifies the medical need for each service; (3) identification of each service, prescription, supply, or plan of care prescribed by the provider; (4) identification of prescription drugs dispensed in accordance with 7 AAC 120.100 - 7 AAC 120.140; (5) stop and start times for time-based billing codes; and (6) annotated case notes identifying each service or supply delivered; the case notes must be dated and either signed or initialed by the individual who provided each service. (e) A provider shall retain a recipient’s records described in (b) - (d) of this section for which services have been billed to the department for at least seven years from the date the service is provided. The duty of the provider set out in this subsection applies to a provider even if the provider’s business is sold or transferred, or is no longer operating. If a provider ceases business, the provider shall notify the department how the department can access Medicaid recipient records in the future. (f) A provider who maintains all or part of the provider’s records in an electronic format shall ensure that the data required to be maintained by this section is readily accessible as required under 7 AAC 105.240(a). (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040


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7 AAC 105.240. Request for records. (a) At the request of the department, the department’s fiscal agent, the Department of Law, or a representative of the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS), a provider shall provide the records described in 7 AAC 105.230(b) - (d). The provider shall provide the records that are the subject of the request (1) to the person making the request at the address specified in the request; (2) no later than the deadline for production of the record that is specified in the request, unless the deadline is modified or extended under (c) of this section; (3) without charge; and (4) in the form stated in the request. (b) When a request for records is made under (a) of this section, (1) the provider may provide a copy of the record unless the request specifies that the original record must be provided; and (2) the person making the request may review, copy, or take custody of the original record. (c) Upon the written request of a provider, the department may modify or extend the time period for production of the record. (d) If, in response to a request for a record under (a) of this section, the provider does not produce the record on or before the deadline specified in the request or the deadline modified or extended under (c) of this section, (1) for purposes of an audit, program review, or investigation, the person making the request may consider the record to be nonexistent; and (2) the department may deny a payment or may initiate a recoupment, another procedure to recover an overpayment, or sanctions under 7 AAC 105.410 based on a determination of the record’s nonexistence under (1) of this subsection. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 105.250. Payment from other sources. When payment is received by a provider from a recipient, relative, recipient’s estate, health insurance, or other source, for a covered service that has been or will be paid for by the department, the provider must refund or credit to the department an equivalent amount, up to the department’s liability, or the provider will be subject to recoupment under 7 AAC 105.260. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 105.260. Recouping an overpayment. (a) An overpayment occurs when the department pays a provider (1) for a service without prior authorization when prior authorization is required under 7 AAC 43 or 7 AAC 105 - 7 AAC 160; (2) an amount that exceeds the maximum dollars or units allowed under 7 AAC 43 or 7 AAC 105 - 7 AAC 160; (3) for a service not covered under 7 AAC 43 or 7 AAC 105 - 7 AAC 160; (4) for a service not authorized under the provider’s current provider


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agreement; (5) for a service paid for by another source, or a service eligible for payment by another source; (6) in an amount the provider or the department identifies as an overpayment; (7) in excess of the amount due because of an error or omission of an automated claims processing system; (8) incorrectly for services that do not meet standards established for payment of services; (9) who is not an enrolled Medicaid provider; (10) for a service already paid by the department; (11) for a service provided to a recipient ineligible for Medicaid under AS 47.07 and 7 AAC 100; (12) for a service provided to a recipient eligible for Medicaid under AS 47.07 and 7 AAC 100, but ineligible for the service billed to the department; or (13) in excess of the amount due because of the billing practices of the provider. (b) The department may (1) recoup an overpayment from a provider, without notice to the provider other than as provided by (c) of this section, by reducing future payments to the provider until the overpaid amount has been offset; or (2) arrange with the provider the terms of the provider’s repayment of the overpayment. (c) Before the department (1) recoups an overpayment more than 120 days after the date of the overpayment under (b)(1) of this section, the department will notify the provider in writing at least 60 days before recoupment of the overpayment begins; or (2) recoups an overpayment under (b)(2) of this section, the department will notify the provider in writing at least 60 days before recoupment of the overpayment begins. (d) In the notice under (c) of this section, the department will include (1) the reason for the recoupment; (2) the amount of the overpayment that the department will recoup; and (3) notice of the provider’s right to an appeal under 7 AAC 105.270. (e) If, following receipt of a notice under (c) of this section, the provider discontinues billing the department for Medicaid services, the department will send a written demand to the provider for repayment of the balance of the overpayment. (f) This section does not apply to (1) actions under 7 AAC 105.400 - 7 AAC 105.490, or bankrupt or out-of-business providers; (2) recoupment that is based solely on a prospective payment rate under 7 AAC 150; (3) recoupment actions identified in an audit under 7 AAC 160.100 - 7 AAC 160.130. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 AS 47.05.200


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7 AAC 105.270. First-level provider appeal. (a) A provider may request a first-level appeal of a denied or reduced claim under this section if no later than 180 days after the date on the remittance advice for the claim, a provider submits to the department’s designee (1) a written request for a first-level appeal of the denied or reduced claim that specifies the basis upon which the decision is challenged and includes any supporting documentation; (2) a copy of the original denied or reduced claim and attachments; (3) a copy of the remittance advice relating to the denied or reduced claim; and (4) if applicable, an adjustment or void request completed by the provider correcting the information submitted with the original claim. (b) In an appeal under (a) of this section of a decision that denied the payment of a claim based on the provider’s failure to file the claim before the billing deadline under 7 AAC 145.005(c), the department’s designee shall (1) approve the appeal and pay the maximum amount allowed under 7 AAC 43 and 7 AAC 105 - 7 AAC 160 if the department’s designee determines that

(A) the department committed an error on a claim previously submitted by the provider for the same service to the same recipient on the same day; (B) the claim was timely filed but not processed; or (C) the provider has good cause under 7 AAC 105.280(h) for the provider’s failure to submit the claim before the billing deadline under 7 AAC 145.005(c); or

(2) deny the provider’s appeal if the department’s designee determines that the claim was not timely filed. (c) A provider may request a first-level appeal of a noncertification of hospital admission or length of stay that, under 7 AAC 43 or 7 AAC 105 - 7 AAC 160, requires prior approval by a quality improvement organization, if no later than 180 days after the date of the noncertification of the hospital admission or length of stay notice, a provider submits to the quality improvement organization (1) a written request for a first-level appeal that specifies the basis upon which the decision is challenged and includes any supporting documentation; (2) a complete copy of the recipient’s medical records that support the hospital admission or length of stay and any other supporting documentation; and (3) a copy of the original noncertification notice and attachments. (d) A provider may request a first-level appeal of a decision that denied or reduced prior authorization under 7 AAC 43 or 7 AAC 105 - 7 AAC 160 if, no later than 180 days after the date of that decision, the provider submits a written request for a first-level appeal to the department’s designee. This subsection does not include prior authorizations for services that require certification by a quality improvement organization. The appeal must (1) specify the basis upon which the decision is challenged and include any supporting documentation; and (2) include a copy of the original notice of denial of or reduced prior


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authorization. (e) A provider may request a first-level appeal of a noncertification decision regarding a service that, under 7 AAC 43 or 7 AAC 105 - 7 AAC 160, requires certification by a quality improvement organization in order to obtain prior authorization. The provider must submit the appeal to the quality improvement organization no later than 180 days after the date of the noncertification decision. The request for a first-level appeal must be in writing and include (1) the basis upon which the decision is challenged and any supporting documentation; and (2) a copy of the original noncertification notice and attachments. (f) A provider may request a first-level appeal of a recoupment of overpayment notice issued under 7 AAC 105.260(c). The provider must submit the appeal to the department’s designee no later than 60 days after the date of the notice and include (1) a written request for an appeal that specifies the basis upon which the notice for recoupment of overpayment is challenged and any supporting documentation; and (2) a copy of the recoupment notice under 7 AAC 105.260(c). (g) Except as provided in (l) of this section, a provider that has been denied enrollment by the department or that is disenrolled from Medicaid for a reason other than a reason in 7 AAC 105.400 may appeal the denial or disenrollment under this subsection by submitting (1) a written request that specifies the basis upon which the decision is challenged and includes any supporting documentation; and (2) a copy of the original denial of enrollment or notice of disenrollment. (h) A provider making an appeal under (g) of section must submit the appeal no later than 180 days after the date of the decision to deny enrollment or to disenroll the provider to the department at the address listed in the department’s Addresses for Second Level Provider Appeals list, adopted by reference in 7 AAC 160.900. A decision on appeal under (g) of this section is a final administrative decision, and the department will notify the provider of the provider’s right to appeal to the superior court under the Alaska Rules of Appellate Procedure. (i) The department or its designee may not consider a request for a first-level appeal submitted by a provider under (a) - (g) of this section after the date that the appeal must be submitted. (j) Except under (g) and (h) of this section, a provider that is not satisfied with the first-level appeal decision may file a second-level appeal under 7 AAC 105.280. (k) The provisions of this section do not apply to recoupment actions resulting from audits conducted under 7 AAC 160.100 - 7 AAC 160.130. (l) A provider may not request a first-level appeal of disenrollment under 7 AAC 105.210(d), but may apply for a new enrollment under 7 AAC 105.210. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.074 7 AAC 105.280. Second-level provider appeal. (a) A provider may appeal a first-level appeal decision under 7 AAC 105.270(a) - (f) if the provider submits a written request to the department no later than 60 days after the date of the first-level appeal


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decision. (b) A provider that appeals a first-level appeal decision under this section shall (1) include a description of the issue or decision being appealed; (2) specify the basis upon which the decision is challenged; (3) submit all information and materials that the provider requests the department to consider in resolving the appeal, including a copy of the first-level appeal decision; and (4) submit the appeal to the department at the address listed in the department’s Addresses for Second Level Provider Appeals list, adopted by reference in 7 AAC 160.900. (c) The department will not consider an appeal under this section that is submitted after the date that the appeal must be submitted. (d) In an appeal by a provider under this subsection of a decision that was denied because the provider failed to timely file a claim, the department will (1) approve the appeal and pay the maximum amount allowed under 7 AAC 43 and 7 AAC 105 - 7 AAC 160 if the department determines that

(A) the department committed an error on a claim previously submitted by the provider for the same service to the same recipient on the same day; (B) the claim was timely filed but not processed; or (C) the provider has good cause under (h) of this section for the provider’s failure to submit the claim before the billing deadline under 7 AAC 145.005(c); or

(2) deny the provider’s appeal if the department determines that the claim was not timely filed. (e) Except as provided in (g) of this section, a decision by the department under this section is a final administrative decision, and the department will notify the provider of the provider’s right to appeal to the superior court under the Alaska Rules of Appellate Procedure. (f) The provisions of this section do not apply to recoupment actions resulting from audits conducted under 7 AAC 160.100 - 7 AAC 160.130. (g) The commissioner may review an appeal of a second-level appeal decision for an untimely filed claim from a provider made under (d) of this section for good cause shown. The provider must submit a written request to the commissioner no later than 60 days after the date of the department’s decision made under (d) of this section. A provider shall submit an appeal under this subsection to the Commissioner’s Office, Department of Health and Social Services, PO Box 110601, Juneau, Alaska 99811-0601. A decision by the commissioner under this subsection is a final administrative decision, and the department will notify the provider of the provider’s right to appeal to the superior court under the Alaska Rules of Appellate Procedure. (h) The department will find good cause for a provider’s failure to submit a claim before the billing deadline under 7 AAC 145.005(c) if the failure to submit the claim resulted from a condition that was beyond the provider’s control or was caused by a condition that the provider could not reasonably be expected to prevent. In this subsection, a condition beyond the provider’s control or a condition that the provider could not reasonably be expected to prevent


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(1) includes (A) a weather condition that causes a mail or travel delay; and (B) a disaster such as a fire, flood, or earthquake; and

(2) does not include (A) provider staffing deficiencies; or (B) the recipient's failure to notify the provider of a court, hearing authority, or department decision described in 7 AAC 145.005(c). (Eff. 2/1/2010, Register 193)

Authority: AS 44.77.015 AS 47.05.010 AS 47.07.040 7 AAC 105.290. Reports requested by the department. Upon request by the department, a hospital or physician shall provide a full operative report, interpretation of any film, or a pathologist’s report on tissue removed. The department will not pay a hospital or physician provider for a procedure that requires an operative report or explanation until that report or explanation is received. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040

Article 3. Provider Sanctions and Remedies. Section 400. Grounds for sanctioning providers 410. Sanctions 420. Imposition of sanction 430. Scope of sanction 440. Notice of sanction 450. Provider education 460. Appeal of sanction 470. Restrictions on payments 480. Withholding of payments 490. Definitions 7 AAC 105.400. Grounds for sanctioning providers. The department may impose sanctions for one or more of the following reasons: (1) presenting or causing to be presented for payment any false or fraudulent claim for services or supplies; (2) submitting or causing to be submitted false information for the purpose of obtaining greater compensation than that to which the provider is legally entitled, including charges in excess of a rate established by the department or the provider’s usual and customary charges; (3) submitting or causing to be submitted false information for the purpose of meeting prior authorization requirements; (4) failing to disclose or make available to the department records of services provided to Medicaid recipients and records of payments made for them; (5) failing to provide and maintain quality services to Medicaid recipients within accepted medical community standards as adjudged by a body of professional peers equivalently licensed to practice in this state; (6) engaging in a course of conduct or performing an act the department


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considers deceptive or abusive of the Medicaid program or continuing that conduct following notification that it should cease; (7) breaching the terms of the Medicaid provider agreement or failure to comply with the terms of the provider certification on the Medicaid claims form; (8) overusing the Medicaid program by inducing, or otherwise causing, a recipient to receive services or supplies not required or requested by the recipient; (9) rebating or accepting a fee or portion of a fee or charge for a Medicaid recipient referral; (10) violating any provision of AS 47.07 or any regulation adopted under it; (11) submitting a false or fraudulent application for provider status; (12) violating any law or code of ethics governing the conduct of relevant occupations, professions, or regulated industries; (13) being convicted of a criminal offense relating to performance of a provider agreement with the state or found liable for a negligent act resulting in death or injury to a recipient; (14) failing to meet standards required by state or federal law for participation, including licensure; (15) being excluded from the Medicare program because of fraudulent or abusive practices; (16) following a documented practice of charging recipients for Medicaid services in an amount above the payment made by the department for that Medicaid service; (17) refusing to execute a new provider agreement when requested to do so; (18) failing to correct deficiencies in provider operations after receiving written notice of these deficiencies from the department; (19) being formally reprimanded or censured by an association of the provider’s peers for unethical practices; (20) being suspended or terminated from participation in another governmental medical program such as worker’s compensation under AS 23.30, vocational rehabilitation services under AS 23.15.010 – 23.15.210, and Medicare; (21) failing to repay or make arrangements for repaying an identified overpayment or otherwise erroneous payment; (22) dispensing a lesser quantity of a prescription drug than that prescribed in order to receive multiple dispensing fees for one prescription, unless the prescription drug provider is reducing the prescribed amount in order to dispense no more than a 30-day supply; (23) billing for a prescription drug other than the drug dispensed; (24) billing for an amount in excess of the normal charge to the typical walk-in, cash-paying customer; (25) billing for a prescription refill that was not authorized by the prescriber; (26) falsely submitting a bill specifying that a prescriber required a specific brand name prescription drug rather than a less expensive generic prescription drug that is equivalent;


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(27) supplying false information on a dispensing fee or drug cost survey initiated by the department in order to establish or revise prescription drug payment rates; (28) failing to submit business records, medical records, or other information required by the department for the administration of the Medicaid program; (29) being convicted of, found not guilty by reason of insanity for, or adjudicated a delinquent for a crime identified as a barrier crime under 7 AAC 10.900 - 7 AAC 10.990; (30) failing to comply with the requirements of AS 47.05.310 - 47.05.390; (31) failing to remove from contact with a recipient an employee or agent who is impaired by being under the influence of alcohol or drugs while providing services to a recipient or whose use of alcohol or drugs interferes with work performance or recipient safety; (32) violating, or knowingly allowing an employee to violate, state or federal laws regulating prescription drugs and controlled substances, including forging prescriptions and unlawfully distributing a prescription drug or controlled substance; (33) failing to report to the department facts known to the provider or a provider’s employee regarding the incompetent or illegal practice or conduct of a personal care assistant in connection with personal care services provided under 7 AAC 125.010 - 7 AAC 125.199; (34) submitting or causing to be submitted false information under 7 AAC 125.090; (35) failing to investigate and impose a sanction upon an employee or agent who knowingly submitted false information under 7 AAC 125.090; (36) failing to make available to the department all records of services provided to a recipient and the payments made for those services; (37) performing, or allowing an employee to perform, a service that is beyond that individual’s competence or professional training; (38) failing to perform an act that is within an individual’s competence and training that is necessary to prevent harm or an increase in the risk of harm to a recipient; (39) violating the disclosure of information provisions of 7 AAC 37.010 - 7 AAC 37.130; (40) discriminating, or allowing an employee to discriminate, on the basis of race, religion, color, national origin, ancestry, or sex in the provision of care to a recipient; (41) failing to maintain for each recipient a contemporaneous and accurate record of the services provided; (42) for a health care professional licensed in a jurisdiction, acting or failing to act in a way that would constitute grounds for denial, suspension, or revocation of that individual’s occupational license. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.05.320 AS 47.07.030 AS 47.05.300 AS 47.05.330 AS 47.07.040 AS 47.05.310 AS 47.05.340 7 AAC 105.410. Sanctions. (a) The department may impose the following sanctions against a provider based on the grounds specified in 7 AAC 105.400:


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(1) termination from participation in the Medicaid program; (2) suspension of participation in the Medicaid program; (3) restriction or withholding of payments to a provider; (4) referral to a utilization and quality control peer-review organization; (5) transfer to a closed-end provider agreement not to exceed 12 months or the shortening of an already-existing, closed-end provider agreement; (6) mandatory attendance at provider education sessions, including one-on-one sessions; (7) requirement of prior authorization of services; (8) department review of all claims submitted by a provider before payment to the provider; (9) referral to the applicable jurisdiction licensing board for investigation; (10) referral for fiscal audit under 7 AAC 160.110; (11) public notice of suspension or termination of a provider; (12) reporting the provider to the Healthcare Integrity and Protection Data Bank authorized under 45 C.F.R. Part 61; (13) restrictions on payment under 7 AAC 105.470. (b) In this section, "utilization and quality control peer-review organization" means an organization administered by a grant agency of the federal government and defined under 42 U.S.C. 1320c-1. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 7 AAC 105.420. Imposition of sanction. (a) Except as provided under (c) of this section, if one or more grounds for sanction exist under 7 AAC 105.400, the department will determine which sanction to impose under 7 AAC 105.410. (b) The department will consider the following factors in determining the sanction to be imposed: (1) seriousness of the offense; (2) extent of violations; (3) history of prior violations; (4) prior imposition of sanctions; (5) prior provision of provider education; (6) provider willingness to obey program rules; (7) whether a lesser sanction will be sufficient to remedy the problem; and (8) actions taken or recommended by peer-review groups or licensing boards. (c) The department will initiate proceedings to suspend or terminate a provider from the Medicaid program under 7 AAC 105.410, if a provider or an employee of the provider has (1) been convicted of medical assistance fraud under AS 47.05.210; (2) been convicted of a crime the department considers a risk to the health or safety of a recipient, including a barrier crime under 7 AAC 10.905; (3) been previously suspended under 7 AAC 105.410 due to program abuse or abuse of a recipient; (4) violated 7 AAC 105.430(c); or


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(5) terminated from the Medicare program for fraud or abuse of the Medicare program. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 7 AAC 105.430. Scope of sanction. (a) If the department has suspended or terminated a provider from participation in the Medicaid program under 7 AAC 105.420(c), that provider may not submit a claim, either directly or through another entity, for payment for any service provided to a recipient (1) on or after the date the provider was suspended or terminated; or (2) before the date the provider was suspended or terminated for which the provider had not yet submitted a claim to the department for payment. (b) A Medicaid provider may not submit to the department a claim for payment for a service provided to a recipient if that service was provided by an employee or agent of the provider who has been suspended or terminated from participation in the Medicaid program, except for those services provided before the suspension or termination. Services provided before the suspension or termination are subject to any sanction that may apply to that provider under 7 AAC 105.410. (c) If a provider of services violates (b) of this section, the department may suspend or terminate the provider from participation in the Medicaid program. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 7 AAC 105.440. Notice of sanction. (a) When the department determines that a sanction against a provider is warranted under 7 AAC 105.400 - 7 AAC 105.420, the department will send written notice of the determination to the provider by certified mail. In the notice, the department will include (1) the grounds for sanction under 7 AAC 105.400, including all relevant facts; (2) the proposed sanction to be imposed by the department under 7 AAC 105.410 - 7 AAC 105.420; (3) whether the matter has been referred for fiscal audit under 7 AAC 160.110; (4) any action required of the provider; and (5) the provider’s right to an appeal under 7 AAC 105.460. (b) The proposed sanction is effective 30 days after the date on the notice if the provider does not request an appeal or submit the information required under 7 AAC 105.460 30 days or less after the date on the notice or 30 days after the date of the final administrative appeal decision upholding the proposed sanction. A proposed immediate suspension issued under 7 AAC 160.140 of a provider’s participation in the Medicaid program is effective 10 days after the date on the notice. (c) In addition to the notice under (a) of this section, the department will notify a provider’s known professional societies, the Department of Commerce, Community, and Economic Development, and any other federal or state agency that the department is aware has an interest. In the notification, the department will include the findings made by the department, the sanction imposed, and the date the sanction will begin. (d) If a provider’s participation in the Medicaid program has been suspended or


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terminated, the department will send written notice of that sanction to each recipient for whom the provider has submitted a claim for a service provided in the 12 months preceding the date of the notice of sanction. The department will send the written notice to the last mailing address of the recipient known to the department. The department will also publish notice of the sanction in a newspaper of general circulation or use another method of posting or publication. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 7 AAC 105.450. Provider education. (a) Unless the department has terminated a provider’s participation in the Medicaid program under 7 AAC 105.420, a provider who has received a sanction must participate in a provider education program as a condition of continued participation in the Medicaid program. (b) For each provider who has received a sanction, the department will determine the topics of the provider education program, including (1) claims form completion; (2) the use and format of provider manuals; (3) the use of procedure codes; (4) key provisions of the Medicaid program; (5) payment rates; and (6) how to inquire about coding or billing problems. (c) In addition to the requirements of (a) and (b) of this section, the department may require a provider or employee of a provider to (1) complete a course of study identified by the department; (2) serve a probationary period determined by the department; and (3) reapply for enrollment in the Medicaid program under 7 AAC 105.210. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 7 AAC 105.460. Appeal of sanction. (a) No more than 30 days after the date on the notice of sanction, the provider receiving the notice may request an appeal and a formal hearing. The request for appeal must be in writing and contain a statement and supporting documents that describe the alleged grounds for sanction, specify the basis upon which the sanction is challenged, and explain the reasons that the provider is in compliance with 7 AAC 43 and 7 AAC 105 - 7 AAC 160. A provider may request an expedited appeal of a notice of immediate suspension issued under 7 AAC 160.140. A provider requesting an appeal or expedited appeal under this section must submit the request to the Commissioner’s Office, Department of Health and Social Services, P.O. Box 110601, Juneau, Alaska, 99811-0601. (b) Upon receipt of the request for appeal, if the department is withholding or restricting payment, the department may continue the withholding or restriction of payment until a final determination is made regarding the appropriateness of the sanction. (c) Upon receipt of a request for appeal, the department will schedule a hearing to be held no more than 30 days after receipt of the request. Notice of the date, time, and place of the hearing will be sent to the provider and the provider’s attorney or designated representative. (d) If the sanction proposed by the department is termination of the provider’s


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participation in the Medicaid program based on a failure to meet a standard, including licensure or registration, required by federal or state law for participation in the Medicaid program, a formal hearing is not available. (e) A party may appear and be heard at an appeal proceeding under this section through an attorney or through a designated representative. (f) If a provider does not submit a request for appeal or provide the information required under (a) of this section 30 days or less after the date on the notice of sanction under 7 AAC 105.440, the notice of sanction is the department’s final administrative action. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 7 AAC 105.470. Restrictions on payments. (a) The department may place restrictions on the payment of claims submitted by the provider, including the necessity of the provider to obtain prior authorization of services or to submit to prepayment review of claims, if (1) the department has reason to believe, based on reliable information, that the provider has violated its provider agreement or an applicable statute or regulation, and the department is reviewing, auditing, or investigating the provider’s compliance with the requirements of 7 AAC 43 and 7 AAC 105 - 7 AAC 160; or (2) a state professional licensing or certifying agency is investigating the provider for having committed fraud, abuse, professional misconduct, unprofessional conduct, or a violation of a statute or regulation. (b) The department may continue a restriction imposed under this section until the department issues a notice of informal resolution under (d) of this section or until any related proceedings to impose sanctions against the provider under 7 AAC 105.400 - 7 AAC 105.490 are resolved. (c) Separate from any notice that the department issues under 7 AAC 105.440, the department will send written notice to a provider before it restricts payment under this section. In the notice, the department will (1) identify the restriction and state that it has been imposed on the payment of claims submitted by the provider; (2) state that the restriction will continue until the department issues a written notice of informal resolution under (d) of this section or until any related proceedings to impose sanctions against the provider under 7 AAC 105.400 - 7 AAC 105.490 are resolved; (3) specify, when appropriate, each type of medical assistance claim to which the restriction applies; (4) specify, when appropriate, general allegations that justify the imposition of the restriction; (5) state that the provider’s failure to comply with the restriction imposed under this section may result in the imposition of additional sanctions under 7 AAC 105.410; and (6) inform the provider of the right to submit written information and materials for consideration by the department in resolving the matter. (d) The department will remove the restriction and issue a notice of informal resolution if it determines that a provider did not commit the violations alleged or that the


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violations do not warrant the imposition of sanctions. If the department finds that the provider committed violations, the department will (1) include in the notice of informal resolution a description of each violation, specifying the statute or regulation found to have been violated; and (2) refer the provider to written materials designed to help the provider avoid similar violations in the future. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.05.210 AS 47.07.040 AS 47.05.200 AS 47.05.220 AS 47.07.074 7 AAC 105.480. Withholding of payments. (a) The department may temporarily withhold medical assistance payments to a provider under 7 AAC 105.410, in whole or in part, upon receipt of reliable information that the circumstances giving rise to the need for the withholding involve medical assistance fraud as defined in AS 47.05.210. Regardless of whether it elects to withhold payments under this section, the department will refer the information described in this subsection to the Department of Law. (b) Separate from any notice the department issues under 7 AAC 105.440, the department will send written notice to a provider before it withholds payment under this section. In the notice, the department will (1) state that payments are being withheld in accordance with 42 C.F.R. 455.23 or an applicable provision of state law; (2) state that the withholding is for a temporary period; (3) specify, when appropriate, each type of medical assistance claim to which the withholding applies; (4) specify, when appropriate, general allegations that justify the withholding action; (5) cite the circumstances under which the withholding will be terminated; and (6) inform the provider of the right to submit written evidence for consideration by the department. (c) The withholding of payments to a provider under this section does not preclude the department from imposing other sanctions against the provider under 7 AAC 105.400 - 7 AAC 105.470. (d) The department will cease withholding payments under this section after the department, or a prosecuting authority, determines that there is insufficient evidence to support allegations of fraud against the provider or after legal proceedings against the provider related to the allegations are completed in the provider’s favor on all charges or claims. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.05.210 AS 47.07.040 AS 47.05.200 AS 47.05.220 AS 47.07.074 7 AAC 105.490. Definitions. In 7 AAC 105.400 - 7 AAC 105.490, (1) "closed-end provider agreement" means an agreement that is for a specific period of time not to exceed 12 months and that must be renewed in order for the provider to continue to participate in the Medicaid program; (2) "termination from participation" means a permanent exclusion from participation in the Medicaid program;


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(3) "withholding of payments" means a reduction or adjustment of the amounts paid to a provider on pending and subsequently submitted bills for purposes of offsetting overpayments previously made to the provider. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.05.210 AS 47.07.040 AS 47.05.200 AS 47.05.220 AS 47.07.074

Article 4. Restriction of Recipient's Choice of Providers; Cost-Sharing. Section 600. Restriction of recipient’s choice of providers 610. Recipient cost-sharing 7 AAC 105.600. Restriction of recipient’s choice of providers. (a) The department may restrict a recipient’s choice of medical providers if the department finds that a recipient has used Medicaid services at a frequency or amount that is not medically necessary as provided in (b) and (c) of this section. (b) In order for a recipient to be identified as a potential candidate for restriction under this section, one of the following must occur: (1) a referral is made to the department indicating that the recipient has used a medical item or service at a frequency or amount that is not medically necessary; (2) the recipient receives prescriptions from one or more providers for medication in total average daily doses that exceed those recommended in Drug Facts and Comparisons, adopted by reference in 7 AAC 160.900; (3) the recipient, during a period of not less than three consecutive months, uses a medical item or service with a frequency that exceeds two standard deviations from the arithmetic mean of the frequency of use of the medical item or service by recipients of medical assistance programs administered by the department who have used the medical item or service as shown in the department’s most recent statistical analysis of usage of that medical item or service. (c) Once a recipient is identified under (b) of this section, the department will conduct an individualized clinical review of the recipient’s medical and billing history to determine how the recipient has used the disputed medical item or service and whether that usage was medically necessary. The review must be conducted by a qualified health care professional. The reviewer shall consider (1) the recipient’s age; (2) the recipient’s diagnosis; (3) complications of the recipient’s medical conditions; (4) the recipient’s chronic illnesses; (5) the number of different physicians and hospitals used by the recipient; and (6) the type of medical care received by the recipient. (d) If after the review under (c) of this section is complete the reviewer determines that the recipient’s use of a medical item or service is not medically necessary, the department will (1) monitor the recipient’s usage for 90 days; or (2) notify the recipient in writing that the department will restrict a recipient’s choice of provider as provided in (e) of this section.


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(e) If the department determines that it is necessary to restrict a recipient’s choice of provider under (d)(2) of this section, the department will first offer the recipient the opportunity for a fair hearing in accordance with 7 AAC 49. The department may immediately restrict the recipient’s choice of providers if the recipient does not request a hearing 30 days or less after receiving notice of the department’s intent to impose a restriction. (f) If the department prevails after a fair hearing or the recipient does not request a fair hearing 30 days or less after receiving notice of the department’s intent to impose a restriction, the department will select one primary care provider and one pharmacy within reasonable proximity to the recipient’s home. The department will mark the recipient’s identification card or medical coupons with the word "RESTRICTED" and the name of the designated provider and pharmacy. The recipient may obtain services and items from only the designated provider and pharmacy, except as follows: (1) the recipient may receive medical services from another enrolled provider if the designated provider refers the recipient to the other enrolled provider; (2) the recipient may receive emergency services from any enrolled provider; for purposes of this paragraph, "emergency service" has the meaning given in 7 AAC 105.610(e). (g) The department may only restrict provider choice for a reasonable period of time, not to exceed 12 months of eligibility. The department will review the restriction annually. If the department determines that the restriction should extend beyond 12 months of eligibility, the department will provide the recipient notice and an opportunity for a new fair hearing under (d)(2) and (e) of this section. (h) The designation of the primary care provider or pharmacy under (f) of this section may be changed only if (1) the primary care provider or pharmacy requests the change; (2) the primary care provider or pharmacy disenrolls from the Medicaid program; (3) the recipient moves to a new geographic area; or (4) the department finds that the recipient does not have reasonable access to Medicaid services of adequate quality. (i) Except as provided in (f) of this section, the department will pay only a provider designated under this section for the provision of medical services to a recipient whose identification card or medical coupons are marked "RESTRICTED." (j) In this section, "qualified health care professional" means a health care provider who is licensed under AS 08 and whose area of licensure relates to the service or item identified under (b) of this section. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 105.610. Recipient cost-sharing. (a) Except as provided in (b) of this section, a person eligible for Medicaid under 7 AAC 100 shall pay the following cost-sharing amounts: (1) $50 per day up to a maximum of $200 per discharge for inpatient hospital services; (2) five percent of allowable charges for outpatient hospital services; (3) $3 per day for physician services;


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(4) $2 for each prescription for prescribed drugs that is filled or refilled. (b) The following services are not subject to recipient cost-sharing requirements under this section: (1) a service provided to a recipient under 18 years of age at the time of delivery of the service; (2) a service provided to a recipient in a long-term care facility; (3) a service provided to a pregnant woman, including a service provided during the postpartum period; (4) a family planning service or supply; (5) an emergency service; (6) a hospice care service; (7) a service provided to an American Indian or an Alaska Native by a tribal health program; (8) a service provided to an individual who is eligible for both Medicaid and Medicare, if Medicare is the primary payer for that service. (c) A provider shall collect the amount of cost-sharing from the recipient and otherwise comply with AS 47.07.042(a) concerning cost-sharing. (d) The department will reduce payment to the provider by the amount of cost-sharing required under this section for the service provided to that recipient. (e) In this section, "emergency service" means (1) inpatient hospital care provided to a recipient admitted into the hospital from the emergency room of that hospital; and (2) outpatient hospital services and physician services provided to a recipient in response to the sudden and unexpected onset of an illness or accidental injury that requires immediate medical attention to safeguard the recipient’s life; in this paragraph "immediate medical attention" means medical care that the department determines cannot be delayed for 24 hours or more after the onset of the illness or occurrence of the accidental injury. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.020 AS 47.07.042


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Chapter 110. Medicaid Coverage; Professional Services. Article 1. Advanced Nurse Practitioner Services (7 AAC 110.100 - 7 AAC 110.105) 2. Chiropractic Services (7 AAC 110.120) 3. Dental Services (7 AAC 110.140 - 7 AAC 110.160) 4. Direct-Entry Midwife Services (7 AAC 110.180) 5. EPSDT Services (7 AAC 110.200 - 7 AAC 110.210) 6. Family Planning Services (7 AAC 110.230) 7. Imaging Services (7 AAC 110.240) 8. Nurse Anesthetist Services (7 AAC 110.250) 9. Nutrition Services (7 AAC 110.270 - 7 AAC 110.280) 10. Physician Services (7 AAC 110.400 - 7 AAC 110.455) 11. Podiatry Services (7 AAC 110.500 - 7 AAC 110.505) 12. Private-Duty Nursing Services (7 AAC 110.520 - 7 AAC 110.530) 13. Psychologist Services (7 AAC 110.550) 14. Targeted Case Management (7 AAC 110.600) 15. Telemedicine Services (7 AAC 110.620 - 7 AAC 110.639) 16. Vision Care Services (7 AAC 110.700 - 7 AAC 110.715)

Article 1. Advanced Nurse Practitioner Services. Section 100. Advanced nurse practitioner enrollment requirements 105. Advanced nurse practitioner services 7 AAC 110.100. Advanced nurse practitioner enrollment requirements. (a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing advanced nurse practitioner services, including nurse midwife services, a provider must be an independent practicing advanced nurse practitioner who (1) is enrolled in as an advanced nurse practitioner in accordance with 7 AAC 105.210; (2) has an active license to practice as an advanced nurse practitioner issued by the jurisdiction in which the individual provides services; if services are provided in this state, the individual must hold an active license under AS 08.68; (3) has a current advanced nurse practitioner certification in a specialty area of nursing granted by a national certification body recognized by the licensing authority for advanced nurse practitioners in the jurisdiction in which the advanced nurse practitioner provides services; and (4) if the advanced nurse practitioner prescribes legend drugs, has a valid license endorsement issued by the jurisdiction in which the individual provides services authorizing the advanced nurse practitioner to prescribe legend drugs; if legend drugs are prescribed in this state, the advanced nurse practitioner must be authorized to prescribe drugs by the Board of Nursing under 12 AAC 44.440. (b) In addition to meeting the requirements of (a) of this section, to be eligible for payment for laboratory services performed in the advanced nurse practitioner’s own laboratory, an advanced nurse practitioner must have a CMS Clinical Laboratory Improvement Amendments (CLIA) certificate of waiver under 42 C.F.R. 493.35 - 493.37


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or a registration certificate under 42 C.F.R. 493.43 - 493.45. A copy of the CLIA certificate of waiver or registration certificate must be submitted with the application for enrollment under 7 AAC 105.210. (c) In addition to meeting the requirements of (a) of this section, to be eligible for payment for dispensing legend drugs, an advanced nurse practitioner must also be enrolled as a dispensing provider under 7 AAC 120.100. (d) The department will not pay an advanced nurse practitioner enrolled under 7 AAC 105.210 and this section for services the advanced nurse practitioner provided as a salaried employee of a hospital or services for which the advanced nurse practitioner, through an agreement with a hospital, received compensation in cash or in-kind from the hospital. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 110.105. Advanced nurse practitioner services. (a) The department will pay an advanced nurse practitioner who meets the requirements of 7 AAC 110.100 for services provided that are within the scope of the advanced nurse practitioner’s license to practice, including (1) primary care, including

(A) diagnosis and treatment of an illness or injury for children or adults; and (B) immunizations to a recipient

(i) under 21 years of age; (ii) 21 years of age or older, in accordance with 7 AAC 110.405(b)(2);

(2) early and periodic screening, diagnosis, and treatment services; and (3) if applicable, dispensing of legend drugs in accordance with 7 AAC 110.100 and 7 AAC 120.100. (b) The department will pay an advanced nurse practitioner certified as a nurse midwife for services for a normal vaginal delivery performed at a free-standing birth center licensed under AS 47.32. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040

Article 2. Chiropractic Services. Section 120. Chiropractic coverage and limitations 7 AAC 110.120. Chiropractic coverage and limitations. (a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing chiropractic services, a chiropractor must (1) be enrolled as a chiropractor in accordance with 7 AAC 105.210; (2) have an active license to practice chiropractic issued by the jurisdiction in which the chiropractor provides services; if services are provided in this state, the individual must hold an active license under AS 08.20. (b) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing chiropractic services in a group practice, the group must (1) be enrolled in accordance with 7 AAC 105.210; and


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(2) be comprised of one or more individuals who meet the requirements of (a) of this section. (c) The department will only pay for chiropractic services identified in the CPT Fee Schedule for Chiropractic Services table adopted by reference in 7 AAC 160.900. Subject to the limitations in (d) of this section, the department will pay for manual manipulation to correct a subluxation of the spine, and x-rays necessary for diagnosis, if the subluxation of the spine resulted in a neuromusculoskeletal condition for which manual manipulation is the appropriate treatment. If there is no x-ray to support that a subluxation exists, the recipient’s record must contain complete documentation of the examination results justifying manual manipulation for subluxation of the spine. (d) The department will not pay for the following chiropractic services: (1) chiropractic services for an individual 21 years of age or older; (2) more than 12 visits to a chiropractor by a recipient in a calendar year; (3) x-rays, except for a diagnostic x-ray of the specific area of the spine requiring treatment; (4) more than one x-ray billing code during a calendar year for a recipient; (5) chiropractic services for a child under six years of age, unless the department has given prior authorization for the service and the service is supported by a referral from a physician, advanced nurse practitioner, or physician assistant; (6) a chiropractic service for which the department has not established a payment rate under 7 AAC 145.110. (e) A chiropractor must maintain in the chiropractor’s place of business a recipient medical record, either written or electronic, containing complete documentation of the examination results justifying manual manipulation for subluxation of the spine when there is no supporting x-ray. (f) In this section, "subluxation" has the meaning given "subluxation complex" in AS 08.20.900. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040

Article 3. Dental Services. Section 140. Dental provider enrollment requirements 145. Dental services for adults 150. Dental services for recipients under 21 years of age 155. Dentist-administered anesthesia and sedation 160. Diagnostic x-ray 7 AAC 110.140. Dental provider enrollment requirements. (a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing dental services, a dentist must (1) be enrolled as a dentist in accordance with 7 AAC 105.210; (2) have an active license to practice dentistry issued by the jurisdiction in which the dentist provides services; if services are provided in this state, the individual must hold an active license under AS 08.36; and (3) if practicing orthodontics, have an active certification from the appropriate specialty board recognized under AS 08.36.246.


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(b) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing dental services in a group practice, the group must (1) be enrolled in accordance with 7 AAC 105.210; and (2) be comprised of one or more individuals who meet the requirements of (a) of this section. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 110.145. Dental services for adults. (a) The department will pay for recipients 21 years of age or older for dental services for the immediate relief of pain and acute infection, except as specifically excluded under (c) of this section. Payment for services covered under this subsection does not reduce the recipient’s annual limit under (b) of this section. The services covered under this subsection include (1) minimal services for the immediate relief of pain and acute infection; (2) general anesthesia and sedation; and (3) diagnostic examination or radiographs necessary for emergency dental care. (b) The department will pay for dental claims under this section that are applied toward a recipient’s annual limit for service dates from July 1 to June 30 of that year. On July 1 of each year, a recipient’s annual limit returns to the maximum limit permitted under this section. The department will pay, up to an annual limit of $1,150 per recipient 21 years of age or older, for the following dental services: (1) diagnostic examination or radiographs necessary for routine dental care; (2) preventative care, including

(A) prophylaxis, including necessary scaling, polishing, and instructions; (B) topical fluoride application; and (C) an anterior removable space maintainer;

(3) restorative care, including amalgams, resins, stainless steel crowns, and full crowns for restoration of decayed or fractured teeth; temporary restorations, cement bases, and local anesthesia are considered components of a complete restorative procedure and may not be billed separately; (4) endodontics, with the following limitations:

(A) palliative and sedative treatments may not exceed two times per tooth before a definitive treatment; (B) pulp capping must be necessary for a direct pulp cap of an exposed pulp of a permanent tooth; (C) root canal therapy must include tooth preparation, filling of the root canal, and follow-up; (D) a separate claim may be made for pin retention and restoration, not to exceed five surfaces per tooth;

(5) periodontics, including treatment of pain or acute infection of supporting tissues of the teeth, including gingivitis, periodontitis, and periodontal abscess; (6) prosthodontics, including complete or partial dentures and denture repair or reline; the department will pay for replacement of complete or partial dentures


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only once per five calendar years; (7) oral surgery; local anesthesia, materials, and routine postoperative care are considered components of a complete surgical procedure and may not be billed separately; (8) professional consultation, if medically necessary or as requested by the department. (c) The department will not pay for the following dental services provided to a recipient 21 years of age or older: (1) panoramic radiograph more than once in a calendar year; (2) final restorations in amalgam or resin for more than five surfaces; (3) dental sealants; (4) restoration of etched enamel or deep grooves without dentin involvement; (5) inlays, overlays, or three-fourth crowns; (6) endodontic apical surgery or retrograde fillings; (7) periodontal surgery; (8) implant or implant-related dental services; (9) orthodontic services. (d) Notwithstanding 7 AAC 145.015, for services provided under (b) of this section a provider may bill a recipient for the difference between the full payment and the amount remaining in the recipient’s annual limit if the annual limit would provide less than the full payment for the service. (e) A provider shall inform a recipient in advance of the recipient’s obligation to pay for a service if the recipient’s annual limit has already been reached or if the amount due will cause the recipient’s annual limit to be exceeded. The provider shall document in the recipient’s records that the recipient was provided that information and agreed to pay for any balance above the annual limit for the service provided. (f) The department will not pay a provider for a recipient’s missed appointment. If the provider has a policy to charge patients for missed appointments, the provider may charge the recipient. (g) A dental service provided when a recipient’s annual limit has been reached is considered a non-Medicaid service. The recipient is responsible for the full amount due for the service. The department will not provide payment if the recipient’s annual limit has been reached. (h) For a recipient 21 years of age or older, dental services must have prior authorization from the department. The department will assist a provider and recipient to the extent possible in monitoring the recipient’s annual limit. However, the department will not assume financial responsibility for services provided that exceed the recipient’s annual limit. When requesting prior authorization, a provider must include, on a form provided by the department, the (1) name of the recipient to whom dental services were provided; (2) type of dental services provided; and (3) charge for the services provided. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.067 AS 47.07.030


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7 AAC 110.150. Dental services for recipients under 21 years of age. (a) The department will pay for the following dental services, as described, provided to a recipient under 21 years of age: (1) diagnostic examination and radiographs as needed for routine and emergency dental care; (2) preventative care, including

(A) prophylaxis, including necessary scaling, polishing, and instructions on oral hygiene and diet; (B) fluoride treatment applied topically; (C) sealants, limited to once per calendar year per tooth; (D) space management therapy restricted to posterior teeth; if primary teeth, the department will pay for a space maintainer if a significant risk exists of detrimental drifting occurring before the permanent tooth erupt; if permanent teeth, the department will pay for a simple space maintainer if prosthodontic treatment is not applicable;

(3) restorative care, including amalgams and resin restorations for the treatment of decayed or fractured teeth; the department will pay for a preformed stainless steel or preformed plastic crown, if the tooth cannot be restored with amalgams or resin; tooth preparation, sedative and cement base, and local anesthesia are considered components of a complete restorative procedure and may not be billed separately; (4) endodontics, with the following limitations:

(A) palliative and sedative treatments may not exceed two times per tooth before a definitive treatment; (B) pulp capping must be necessary for a direct pulp cap of an exposed pulp of a permanent tooth; (C) root canal therapy must include tooth preparation, filling of the root canal, and follow-up; and (D) a separate claim may be made for pin retention and restoration, not to exceed five surfaces per tooth;

(5) periodontics, including treatment of pain or acute infection of supporting tissues of the teeth, including necrotizing ulcerative gingivitis, acute primary herpetic gingivostomatitis, dilantin hyperplasia, and periodontal abscess; (6) prosthodontics, including complete or partial resin-based dentures and denture repair or reline; the department will pay for replacement of complete or partial resin-based dentures only once per five calendar years; (7) oral surgery; local anesthesia, materials, and routine postoperative care are considered components of a complete surgical procedure and may not be billed separately; (8) orthodontic services, if

(A) the orthodontics is for a severe condition that requires the combined skills of an orthodontist and an oral surgeon; for purposes of this subparagraph, severe conditions include cleft palate and class III skeletal malformations; (B) the request for orthodontics is accompanied by a plan of care and documentation of the recipient’s condition, including cephalametric x-ray, panelipse, study models, photographs, articulate way models, periapical x-rays,


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and reports that confirm that the oral surgeon and orthodontist agree on the necessity for orthodontics; and (C) the department gives prior authorization for the request for orthodontics;

(9) anesthesia and sedation if administered in accordance with 7 AAC 110.155; (10) professional consultation, if medically necessary or if requested by the department; (11) office visits, if an antibiotic is prescribed or administered for infections, swelling, or pain without any further billable treatment that day. (b) The department will not pay for the following dental services for recipients under 21 years of age: (1) final restoration in resin or amalgam for more than five surfaces; (2) indirect pulp capping; (3) space maintainers for anterior teeth; (4) restoration of etched enamel or a deep groove without obvious dentin involvement; (5) denture characterization and personalization, implants, and precision attachments; (6) experimental procedures; (7) treatment for conditions of the temporomandibular joint. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 110.155. Dentist-administered anesthesia and sedation. (a) The department will pay for general anesthesia, nitrous oxide sedation, intravenous sedation, intramuscular sedation, or oral sedation, without prior authorization, if the dental services provider justifies, in writing, that the service is required for a patient who is uncontrollable under local anesthesia alone; justification may include (1) severe mental retardation; (2) spastic type disability; (3) severe behavioral problems; (4) failure of a local anesthetic to control pain; (5) extreme apprehension; or (6) a prolonged or difficult surgical procedure. (b) The cost of the supplies necessary for the administration of anesthesia and sedation, including drugs, nitrous oxide masks, tubing, and syringes, are included in the payment made under (a) of this section. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 110.160. Diagnostic x-ray. The department may, in the process of utilization review or determining its responsibility for payment of dental services, request that the treating dentist submit appropriate diagnostic x-rays to the department. If the department requests submission of diagnostic x-rays, it will not make payment unless the x-rays are submitted. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040


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Article 4. Direct-Entry Midwife Services.

Section 180. Direct-entry midwife coverage and limitations 7 AAC 110.180. Direct-entry midwife coverage and limitations. (a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing direct-entry midwife services, a direct-entry midwife must (1) be enrolled as a direct-entry midwife in accordance with 7 AAC 105.210; and (2) have an active license or certification to practice as a direct-entry midwife issued by the jurisdiction in which the individual provides services; if services are provided in this state, the individual must be certified under AS 08.65. (b) Direct-entry midwife services are those services for the management of prenatal, intrapartum, and postpartum care that direct-entry midwives are certified to provide under 12 AAC 14. Postpartum care begins on the date the pregnancy ends and extends through the end of the month in which the 60th calendar day after the date the pregnancy ends falls. The department will only pay for direct-entry midwife services identified in the CPT Fee Schedule for Direct Entry Midwife Services table and HCPC Fee Schedule for Direct-Entry Midwife Services table, adopted by reference in 7 AAC 160.900. (c) The department will not enroll a direct-entry midwife in training or an apprentice. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040

Article 5. EPSDT Services. Section 200. Purpose of EPSDT services 205. EPSDT screening services 210. EPSDT covered services 7 AAC 110.200. Purpose of EPSDT services. The department will pay for early and periodic screening, diagnosis, and treatment (EPSDT) services provided to a recipient under 21 years of age. EPSDT services include (1) screening for physical, behavioral, vision, dental, and hearing needs that meet the requirements of 7 AAC 110.205; and (2) any necessary health care, diagnostic services, treatment, or other services that meet the requirements of 7 AAC 110.210. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 110.205. EPSDT screening services. (a) To be covered under 7 AAC 105 - 7 AAC 160, an EPSDT screening must be performed by one or more of the following providers enrolled under 7 AAC 105 - 7 AAC 160: (1) a physician; (2) a licensed or certified health care practitioner who performs a screening under the supervision of a physician, if the health care practitioner may


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perform screenings under the health care practitioner’s scope of license or certification; (3) the department; (4) a tribal health program; (5) an advanced nurse practitioner; (6) a rural health clinic or federally qualified health center; (7) a municipal health department; (8) a school district. (b) To be covered under 7 AAC 105 - 7 AAC 160, an EPSDT screening must include (1) a comprehensive medical screening that meets the minimum standards of the Alaska Periodicity Schedule for Child and Adolescent Health Screening, adopted by reference in 7 AAC 160.900, with additional screenings performed as medically necessary; a comprehensive medical screening must include

(A) a comprehensive health and developmental history, including a behavioral health history; (B) an unclothed physical examination, including a head-to-toe systemic review; (C) a developmental assessment, including gross and fine motor development, communication skills and language development, self-help and self-care skills, and social-emotional development; (D) a determination of immunization status and administration of immunizations

(i) in accordance with the Alaska Immunization Recommendations, adopted by reference in 7 AAC 160.900; and (ii) that may include other vaccines not on the periodicity schedule that are approved by the Advisory Committee on Immunization Practices, in the United States Department of Health and Human Services, Centers for Disease Control and Prevention; the department will notify providers when a vaccine is added or deleted from the periodicity schedule;

(E) a determination of nutritional status; (F) health-related measurements, including height, weight, and other appropriate measures and indicators of health; (G) hemoglobin or hematocrit testing conducted in accordance with the periodicity schedule, unless more frequent testing is medically necessary; (H) other tests and procedures that are conducted in accordance with the periodicity schedule or are age appropriate and medically necessary, including blood pressure, urinalysis, pap smears, and pelvic examinations; (I) an intradermal purified protein derivative (PPD) skin test for tuberculosis conducted in accordance with the periodicity schedule; (J) a referral to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) under 42 U.S.C. 1786, if a recipient does not already participate in the program and is under five years of age or pregnant; (K) referrals to other medical providers and programs, as appropriate to the recipient’s age and condition; and (L) health education, including anticipatory guidance.


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(2) a dental screening that includes a referral to a dental services provider at three years of age and semiannual examinations by a dental services provider thereafter; if medically necessary, the department will pay for

(A) more frequent examinations by a dental services provider; or (B) a referral to a dental services provider before the child is three years of age;

(3) a vision screening that includes a referral to a vision care services provider at five years of age and annually thereafter; if medically necessary, the department will pay for

(A) more frequent examinations by a vision care services provider; or (B) a referral to a vision care services provider before the child is five years of age;

(4) a hearing screening and, if medically necessary, referral for diagnosis and treatment of defects in hearing; and (5) a lead screening appropriate for age and risk factors. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 110.210. EPSDT covered services. (a) The department will pay for a service recommended as a result of the EPSDT screening, if that service is an authorized service under 42 U.S.C. 1396 - 1396w-1. (b) The department will pay for the following additional services for children under 21 years of age if the screening identifies a need for that service: (1) podiatry services under 7 AAC 110.500 - 7 AAC 110.505; (2) nutrition services under 7 AAC 110.275; (3) private-duty nursing services under 7 AAC 110.520 - 7 AAC 110.535; (4) hospice care under 7 AAC 140.280. (c) The department will pay for transportation services identified in (d) of this section if, before the date of travel, the recipient or provider requests prior authorization for travel from the department and if the department determines that (1) the transportation is needed to

(A) obtain an EPSDT screening or medically necessary service identified by an EPSDT screening; (B) obtain a prenatal screening and resulting referrals; (C) attend an appointment with a local office responsible within the department for implementing the Special Supplemental Nutrition Program for Women Infants, and Children (WIC) under 42 U.S.C. 1786; (D) obtain necessary medical care for a recipient under 21 years of age, if

(i) the medical care involves intercommunity travel; (ii) the medical care is not the result of an EPSDT screening; (iii) the recipient lives in a community not served by a common carrier; and (iv) the recipient is not eligible for transportation services


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under 7 AAC 120.400 - 7 AAC 120.490; or (E) obtain a prescription that is required as a result of an EPSDT or prenatal screening;

(2) the recipient is under 21 years of age and eligible for Medicaid under 7 AAC 100; (3) other appropriate transportation services are not available; and (4) the medical service requested is not available closer to the recipient’s residence. (d) The department will pay for the following transportation services authorized under (c) of this section: (1) a bus token or pass; (2) a taxi, shuttle, or similar form of ground transportation; (3) a mileage payment for use of a private vehicle driven for medical purposes. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040

Article 6. Family Planning Services. Section 230. Family planning services 7 AAC 110.230. Family planning services. (a) The department will pay for family planning services authorized under this section if those services are provided by one of the following enrolled providers: (1) a family planning clinic of the department; (2) a family planning clinic of a local governmental health department; (3) a student health service operated by an educational institution; (4) a private family planning clinic; (5) a physician, advanced nurse practitioner, or physician assistant; (6) a federally qualified health center or rural health clinic. (b) A family planning service provider that operates its own laboratory must have a CMS Clinical Laboratory Improvement Amendments (CLIA) certificate of waiver under 42 C.F.R. 493.35 - 493.37 or a registration certificate under 42 C.F.R. 493.43 - 493.45. (c) An out-of-state family planning services provider must (1) meet the definition of a family planning services provider in the jurisdiction in which services are provided; (2) be enrolled in the jurisdiction in which it provides services; and (3) enroll as a family planning services provider in this state. (d) The department will pay for the following family planning services provided by a family planning services provider authorized under this section: (1) office visits for counseling services identified by one of the procedure codes in the range of 99201 to 99215 in Current Procedural Terminology (CPT), adopted by reference in 7 AAC 160.900; (2) laboratory services performed by a family planning services provider that meets the certificate requirements of (b) of this section; and (3) prescription drugs prescribed in accordance with 7 AAC 120.100 -


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7 AAC 120.140. (e) The department will not pay separately for (1) office supplies and services associated with office visits and procedures identified in (d) of this section; or (2) handling or conveyance of a specimen from one provider to another under procedure codes 99000 and 99001 in Current Procedural Terminology (CPT), adopted by reference in 7 AAC 160.900. (f) In this section, "family planning services" (1) means services and materials provided with the purpose of postponing, avoiding, or terminating pregnancy; (2) includes the dispensing of birth control drugs and devices for males and females, and the performance of vasectomies, sterilizations, and abortions for the purpose of avoiding or terminating pregnancy. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040

Article 7. Imaging Services. Section 240. Imaging services 7 AAC 110.240. Imaging services. To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing in-state freestanding or portable x-ray services the provider must be enrolled as a provider of those services in accordance with 7 AAC 105.210, and must (1) be certified by the department under 42 C.F.R. 488.11 and 488.26 to be in compliance with 42 C.F.R. 486.100 - 486.110, adopted by reference in 7 AAC 160.900; or (2) hold a valid mammography equipment certificate issued by the United States Food and Drug Administration under 21 C.F.R. 900.11. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040

Article 8. Nurse Anesthetist Services. Section 250. Registered nurse anesthetist enrollment and services 7 AAC 110.250. Registered nurse anesthetist enrollment and services. (a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing registered nurse anesthetist services directly to a recipient, a provider must (1) be enrolled as a registered nurse anesthetist under 7 AAC 105.210; and (2) except as provided in (b) of this section, hold an active license or certification as a registered nurse anesthetist issued by the jurisdiction in which the individual provides services; if services are provided in this state the individual must hold an active license under AS 08.68 and an active authorization under 12 AAC 44.500 - 12 AAC 44.560. (b) The department will pay a registered nurse anesthetist only for services within


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the scope of practice of a registered nurse anesthetist under AS 08.68 and 12 AAC 44. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040

Article 9. Nutrition Services. Section 270. Nutrition services provider enrollment requirements 275. Nutrition services for recipients under 21 years of age 280. Nutrition services for pregnant women 7 AAC 110.270. Nutrition services provider enrollment requirements. To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing nutrition services, a provider must (1) be enrolled as a dietitian or nutritionist in accordance with 7 AAC 105.210; and (2) have an active license to practice as a dietitian or nutritionist issued by the jurisdiction in which the individual provides services; if services are provided in this state, the individual must hold an active license to practice under AS 08.38. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 110.275. Nutrition services for recipients under 21 years of age. (a) The department will pay for outpatient nutrition services provided to a recipient under 21 years of age who (1) receives an EPSDT screening under 7 AAC 110.205 no more than 12 months before or no more than one month after service is provided; and (2) consistent with the criteria in (b) of this section, is determined to be at high risk nutritionally by a physician, an advanced nurse practitioner, or another licensed or certified health care practitioner who may order those services within the scope of the practitioner’s license or certification. (b) A recipient under 21 years of age is at high risk nutritionally if the recipient (1) has a flat growth curve or failure to thrive; (2) has an atypical height-to-weight ratio, head circumference, or sudden weight change; (3) has a hemoglobin count of less than 10 grams or a hemostat of less than 30 percent; (4) has a weight of 2,500 grams or less, or a gestation of 36 weeks or less at birth; (5) has a chronic disease or condition, including diabetes, cystic fibrosis, kidney disease, cancer, colitis, hypertension, diarrhea, constipation, anemia, and infection; (6) has a congenital anomaly or genetic disorder, including cleft lip or palate, Down syndrome, spina bifida, heart disease, and phenylketonuria; (7) is pregnant or breast-feeding; or (8) has a growth problem with a nutritional condition that requires a special formula or diet.


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(c) The department will pay for the following nutrition services provided to a recipient who meets the requirements of (a) and (b) of this section: (1) one initial assessment in a calendar year; (2) up to 12 hours of services in a calendar year for counseling and follow-up care after the initial assessment for counseling and follow-up care; (3) more than 12 hours of service in a calendar year if those hours are

(A) medically justified and prescribed by a physician, an advanced nurse practitioner, or a physician assistant, who may order those services within the scope of the practitioner’s license; and (B) given prior authorization by the department.

(d) The department will pay an independently practicing enrolled provider of nutrition services directly. If a provider of nutrition services provides services as a member of the staff of a hospital or other facility that is a Medicaid provider, the department will make payment to the facility. The department will not separately pay for inpatient nutrition services provided to a recipient in a hospital or nursing facility. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 110.280. Nutrition services for pregnant women. (a) The department will pay for outpatient nutrition services provided to a recipient who is (1) pregnant; (2) consistent with the criteria in (b) of this section, determined to be at high risk nutritionally by

(A) a physician, an advanced nurse practitioner, or a physician assistant who may order those services within the scope of the practitioner’s license or certification; or (B) a licensed dietitian or nutritionist employed by a hospital or the state’s Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) under 42 U.S.C. 1786.

(b) A pregnant recipient is at high risk nutritionally if the recipient (1) has a chronic or metabolic disease; (2) has a disease or condition that requires a prescribed therapeutic diet; (3) was underweight before conception; (4) has inadequate or excessive weight gain during pregnancy; (5) has a history of substance abuse; (6) has a history of low birth-weight infants; (7) has multiple fetuses; (8) has anemia; (9) has intrauterine growth retardation; or (10) is less than 16 years of age. (c) The department will pay for the following nutrition services provided to a pregnant woman who meets the requirements of (a) and (b) of this section: (1) one initial assessment in a calendar year; (2) up to 12 hours of services in a calendar year for counseling and follow-up care after the initial assessment; (3) more than 12 hours of service in a calendar year if those hours are


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(A) medically justified and prescribed by a physician, an advanced nurse practitioner, or a physician assistant who may order those services within the scope of the practitioner’s license; and (B) given prior authorization by the department. (Eff. 2/1/2010, Register 193)

Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040

Article 10. Physician Services. Section 400. Physician services provider enrollment requirements 405. Physician services coverage and limitations 410. Physician services in a nursing facility 415. Sterilization by a physician 420. Hysterectomy by a physician 425. Obstetrical care by a physician 430. Office medical supplies 435. Physician laboratory services 440. Physician radiology and imaging services 445. Mental health services by a physician 450. Surgical assistant 455. Physician assistant enrollment and services 7 AAC 110.400. Physician services provider enrollment requirements. (a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing physician services, the provider must (1) be enrolled as a physician in accordance with 7 AAC 105.210; and (2) have an active license to practice medicine or osteopathy issued by the jurisdiction in which the physician provides services; if services are provided in this state the individual must hold an active license under AS 08.64. (b) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing physician services in a group practice, the group must (1) be enrolled in accordance with 7 AAC 105.210; and (2) be comprised of one or more individuals who meet the requirements of (a) of this section. (c) In addition to meeting the requirements of (a) of this section, to be eligible for payment for laboratory services performed in the physician’s own laboratory, a physician must have a CMS Clinical Laboratory Improvement Amendments (CLIA) certificate of waiver under 42 C.F.R. 493.35 - 493.37 or a registration certificate under 42. C.F.R. 493.43 - 493.45. A copy of the CLIA certificate of waiver or registration certificate must be submitted with the application for enrollment under 7 AAC 105.210. (d) In addition to meeting the requirements of (a) of this section, to be eligible for payment for dispensing prescription drugs, a physician must enroll as a dispensing provider under 7 AAC 120.100. (e) A hospital-based physician must be individually enrolled as a physician under this section. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040


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7 AAC 110.405. Physician services coverage and limitations. (a) Subject to 7 AAC 110.400 - 7 AAC 110.455, the department will pay a physician who meets the requirements of 7 AAC 110.400 for the following services provided within the scope of the physician’s license to practice medicine or osteopathy: (1) any physician services and supplies necessary for diagnosing and treating illness and injury for which a payment rate has been established by the department that meets the requirements of 7 AAC 145.020; (2) preventative health screening and treatment provided as part of the EPSDT program under 7 AAC 110.200 - 7 AAC 110.215; (3) physician services provided in a nursing facility in accordance with 7 AAC 110.410; (4) sterilization performed by a physician in accordance with 7 AAC 110.415; (5) a hysterectomy performed by a physician in accordance with 7 AAC 110.420; (6) speech-language pathology services, if medically necessary; (7) hearing services, if medically necessary; (8) a complete vision examination, including a check of refractive state, if a complete vision examination is clinically indicated and the recipient has significant difficulties or complaints related to vision; (9) anesthesia, if billed in accordance with the American Society of Anesthesiologists' Relative Value Guide, adopted by reference in 7 AAC 160.900; (10) clinical intervention counseling associated with smoking cessation for no more than 10 sessions per calendar year. (b) The department will pay a physician for (1) providing immunizations to a recipient under 21 years of age; (2) the administration of the Influenza A (H1N1) immunization for a recipient 21 years of age or older as medically necessary. (c) The department will pay a physician for providing the following services only if those services are provided to a recipient who is under 21 years of age or who is a Medicare recipient: (1) chiropractic manipulation; (2) podiatry services. (d) The department will not pay for the following services provided by a physician: (1) elective surgery that is not medically necessary; (2) infertility services; (3) case management services; (4) plastic or cosmetic services for enhancement purposes; (5) transsexual surgical procedures or secondary consequences; (6) services provided in the operating room on behalf of the physician by a licensed practical nurse, a registered nurse, an intern, or a resident in training used in the operating room; (7) medical testimony; (8) travel services;


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(9) educational services and supplies; (10) interpreter services; (11) experimental or investigative services; (12) swimming therapy; (13) programs to improve overall fitness; (14) impotence treatment or services; (15) vaccine products that are available free to the provider; (16) physical examinations, except if

(A) given as a screening under the EPSDT program; or (B) the department requests one for the purpose of determining eligibility based upon disability, blindness, or pregnancy;

(17) selected special services and report codes. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 110.410. Physician services in a nursing facility. (a) For a physician visit to a recipient living in a nursing facility, the department will not pay for more than (1) one initial evaluation and management visit per recipient stay; and (2) one subsequent or established care visit per recipient per 30-day period. (b) In addition to a visit covered under (a) of this section, the department will pay for a physician visit if the physician submits supporting documentation substantiating the medical need for the additional visit. (c) The 30-day limit established in (a)(2) of this section does not apply to a physician service provided in response to a medical emergency. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 110.415. Sterilization by a physician. (a) The department will pay for a sterilization performed by a physician only if (1) the recipient is 21 years of age or older; (2) the procedure is for family planning purposes; (3) the recipient has, by signature, given informed consent using the form provided by the department; (4) except as provided in (b) of this section, the procedure was performed no sooner than 30 days, and no later than 180 days, after the date the recipient signed the consent form; (5) the provider signs the consent form before the procedure; and (6) the consent form is attached to the provider claim. (b) The department may waive the 30-day waiting period required in (a)(4) of this section in cases of premature delivery or emergency abdominal surgery if more than 72 hours has passed since the recipient signed the consent form as required in (a)(3) of this section. (c) The department will not accept a consent in any form if it is obtained from anyone in labor of childbirth, under the influence of alcohol or other drugs, seeking or obtaining an abortion, or determined by a court to be incompetent.


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(d) The department will not accept a consent form from a recipient who does not speak English, unless the physician has provided an interpreter or can certify that an interpreter was available and used. (e) The department will not pay for sterilization of an individual who is institutionalized in a correctional facility or inpatient psychiatric facility. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 110.420. Hysterectomy by a physician. (a) The department will pay for a hysterectomy performed by a physician if the (1) department has given prior authorization; (2) procedure is performed for medical reasons; (3) recipient has given her informed consent in writing using the form provided by the department or a form provided by the physician that includes the same information; (4) consent from was signed by the recipient before surgery, unless the provider who performs the surgery certified in writing that

(A) the recipient was sterile before the hysterectomy and states the cause of the sterility; or (B) the hysterectomy was performed under a life-threatening emergency, that is described by the provider, and getting prior consent from the recipient was not possible; and

(5) consent form is attached to the provider claim. (b) The department will not pay for a hysterectomy performed only for the purpose of rendering a woman permanently incapable of reproducing. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 110.425. Obstetrical care by a physician. The department will pay for routine obstetrical care provided by a physician. A physician may not submit a claim for routine global obstetrical care if the recipient does not have third-party health insurance available. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 110.430. Office medical supplies. Office medical supplies routinely associated with physician office visits and procedures are included in the practice cost portion of the resource-based relative value scale (RBRVS) fee schedule developed under 7 AAC 145.050 and are not paid separately. Subject to prior authorization by the department, the department will pay for a nonroutine medical supply provided in a physician’s office. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 110.435. Physician laboratory services. (a) The department will pay for laboratory services provided by a physician in the physician’s own laboratory if the physician holds a CMS Clinical Laboratory Improvement Amendments (CLIA) certificate of waiver under 42 C.F.R. 493.35 - 493.37 or a registration certificate under


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42 C.F.R. 493.43 - 493.45. (b) A physician using the services of an independent laboratory must request services for a recipient in the same manner that services are requested for a private patient. (c) An independent laboratory enrolled in accordance with 7 AAC 105.210 may submit a claim directly to the department. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 110.440. Physician radiology and imaging services. (a) The department will pay for diagnostic and follow-up x-rays without prior approval by the department, but films shall be made available to the department on request. (b) The department will not pay for radiologic contrast material separate from coverage for an x-ray except for low osmolar contrast material (LOCM) used in intrathecal, intravenous, and intra-arterial injections for a recipient with (1) a history of previous adverse reaction to contrast material other than a sensation of heat, flushing, or a single episode of nausea or vomiting; (2) a history of asthma or allergy; (3) significant cardiac dysfunction, including recent or imminent cardiac decompensation, severe arrhythmias, unstable angina pectoris, recent myocardial infarction, or pulmonary hypertension; (4) general severe debilitation; or (5) sickle cell disease. (c) The department will pay for magnetic resonance imaging (MRI), a magnetic resonance angiogram (MRA), and positron emission tomography (PET). However, the department will not pay for magnetic resonance imaging, a magnetic resonance angiogram, or position emission tomography if that service is provide on an outpatient basis, unless the department has given prior authorization for the services. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 110.445. Mental health services by a physician. (a) Subject to the limitations identified in this section, the department will pay for mental health services provided by a physician if those services are (1) medically necessary; (2) rendered directly by that physician; and (3) specified in a treatment plan that meets the requirements of 7 AAC 43.728. (b) The department will pay a psychiatrist for providing health care services in an inpatient psychiatric hospital, general acute care hospital, nursing facility, intermediate care facility for the mentally retarded, or residential psychiatric treatment center. (c) The department will not pay a physician for experimental therapy, nonmedical outpatient therapy, or nonmedical counseling, including any of the following services: (1) telephone consultation; (2) preparing of reports; (3) narcosynthesis;


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(4) socialization; (5) recreation therapy; (6) primal therapy; (7) marathon group therapy; (8) megavitamin therapy; (9) pastoral counseling; (10) employment counseling; (11) explanation of an examination to a family member or other responsible person when the explanation is provided outside of a family therapy session; (12) interaction between recipient and provider by means of the Internet, except as provided in 7 AAC 110.620 - 7 AAC 110.639 for telemedicine services. (d) The department will not pay a psychiatrist for providing group psychotherapy services to a recipient in an inpatient psychiatric hospital or in a general acute care hospital offering psychiatric services. (e) Mental health services rendered by someone other than a physician, an advanced nurse practitioner, a rural health clinic, or a federally qualified health center must be provided in accordance with 7 AAC 43 or 7 AAC 110.550, or must be provided by a tribal health program. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 110.450. Surgical assistant. (a) The department will pay for a physician, an advanced nurse practitioner, or a physician assistant acting as a surgical assistant. A second surgical assistant will be paid at the same rate as the first surgical assistant if the primary surgeon submits a written explanation acceptable to the department that justifies the need for the second surgical assistant. (b) The department will not pay a licensed practical nurse, a registered nurse, an intern, or a resident-in-training acting as a surgical assistant apart from the payment made to the surgeon. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 7 AAC 110.455. Physician assistant enrollment and services. (a) For the department to provide payment under 7 AAC 145.200, a physician assistant who furnishes services directly to a recipient in the state must separately enroll with the department as a rendering provider under 7 AAC 105.210 and (1) unless the physician assistant is a federal employee described in 7 AAC 105.200(c), must

(A) have an active license to practice in the state as a physician assistant under 12 AAC 40.400 - 12 AAC 40.405; (B) submit a copy of the collaborative plan with the supervising physician required under 12 AAC 40.410; and (C) notify the department of any changes to the collaborative plan by submitting a copy of the new plan;

(2) if the physician assistant is a federal employee described in 7 AAC 105.200(c), must

(A) submit a copy of the collaborative plan with the supervising physician, if a collaborative plan is required by the physician assistant's licensing


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jurisdiction; and (B) notify the department of any changes to the collaborative plan by submitting a copy of the new plan.

(b) For the department to provide payment under 7 AAC 145.200, a physician assistant who furnishes services directly to a recipient out of state must separately enroll with the department as a rendering provider under 7 AAC 105.210 and must (1) have an active license to practice in the jurisdiction in which the service is provided unless the physician assistant is a federal employee described in 7 AAC 105.200(c); (2) provide a copy of the collaborative plan with the supervising physician, if a collaborative plan is required by the physician assistant's licensing jurisdiction; (3) provide proof of enrollment in the Medicaid program in the jurisdiction in which the service is provided or documentation from that jurisdiction that physician assistants are not enrolled as Medicaid providers in that jurisdiction; and (4) notify the department of any changes to the collaborative plan by submitting a copy of the new plan. (c) The department will pay for the services of a physician assistant acting as a surgical assistant under 7 AAC 110.450. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040

Article 11. Podiatry Services. Section. 500. Podiatry services provider enrollment requirements 505. Podiatry services 7 AAC 110.500. Podiatry services provider enrollment requirements. (a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing podiatry services, a provider must (1) be enrolled as a podiatrist in accordance with 7 AAC 105.210; and (2) have an active license to practice podiatry issued by the jurisdiction in which the podiatrist provides services; if services are provided in this state the podiatrist must hold an active license under AS 08.64. (b) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing podiatry services in a group practice, the group must (1) be enrolled in accordance with 7 AAC 105.210; and (2) be comprised of one or more individuals who meet the requirements of (a) of this section. (c) In addition to meeting the requirements of (a) of this section, to be eligible for payment for laboratory services performed in the podiatrist’s own laboratory, a podiatrist must have a CMS Clinical Laboratory Improvement Amendments (CLIA) certificate of waiver under 42 C.F.R. 493.35 - 493.37 or a registration certificate under 42 C.F.R. 493.43 - 493.45. A copy of the CLIA certificate of waiver or registration certificate must be submitted with the application for enrollment under 7 AAC 105.210. (d) In addition to meeting the requirements of (a) of this section, to be eligible for payment for dispensing prescription drugs, a podiatrist must enroll as a dispensing


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provider under 7 AAC 120.100. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 110.505. Podiatry services. (a) The department will pay for the podiatry services and supplies identified in the CPT Fee Schedule for Podiatry Services table and HCPC Fee Schedule for Podiatry Services table, adopted by reference in 7 AAC 160.900, provided to a Medicaid recipient under 21 years of age who has been found to need medical services relating to specific conditions of the ankle or foot, if (1) a physician has prescribed the treatment; (2) an EPSDT screening under 7 AAC 110.205 has been completed no more than 12 months before or no more than one month after service; and (3) the treatment provided is within the scope of practice of the treating podiatrist who meets the requirements of 7 AAC 110.500. (b) The department will not pay for podiatry services for individuals 21 years of age or older. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 AS 47.05.012

Article 12. Private-Duty Nursing Services. Section 520. Private-duty nursing agency enrollment requirements 525. Private-duty nursing services; covered and noncovered services 530. Private-duty nursing services; prior authorization 7 AAC 110.520. Private-duty nursing agency enrollment requirements. (a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing private-duty nursing services, a provider must (1) be enrolled as a private-duty nursing agency in accordance with 7 AAC 105.210; and (2) be enrolled as either a hospice service provider under 7 AAC 140.270, or a home health service provider under 7 AAC 125.300, who employs a registered nurse, a licensed practical nurse, or an advanced nurse practitioner. (b) The employee of a private-duty nursing agency who furnishes services directly to a recipient must (1) be separately enrolled as

(A) a rendering provider of private-duty nursing services in accordance with 7 AAC 105.200(b) and 7 AAC 105.210, if the rendering provider is a licensed practical nurse or a registered nurse; or (B) an advanced nurse practitioner in accordance with 7 AAC 105.200(a) and 7 AAC 105.210;

(2) have an active license to practice as a registered nurse, a licensed practical nurse, or an advanced nurse practitioner issued by the jurisdiction in which the nurse provides services; if services are provided in this state the nurse must hold an active license under AS 08.68; and (3) if practicing out of state, be enrolled as a provider or rendering provider of private-duty nursing services in the jurisdiction in which services are


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provided. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 110.525. Private-duty nursing services; covered and noncovered services. (a) The department will pay for private-duty nursing services, if they are provided to a recipient who (1) is under 21 years of age; (2) has been recently discharged from a general acute care hospital or long-term care facility, or has a physical health status that would justify admission to a general acute care hospital or long-term care facility; (3) with the provision of private-duty nursing services, will be able to live in a family setting, and for whom those services will prevent admission to, or promote early discharge from, a general acute care hospital or long-term care facility; (4) requires more individual and continuous care than is available from a visiting nurse or is routinely provided by the nursing staff of a hospital, a skilled nursing facility, or an intermediate care facility; in this paragraph, "continuous care" means a minimum of eight hours provided to an individual in a 24-hour period; and (5) has had a full or partial EPSDT screening under 7 AAC 110.200 completed no more than 12 months before or no more than one month after private-duty nursing services were provided to that individual. (b) The department will pay for private-duty nursing services only if (1) the services are for a life threatening condition, and a private-duty nursing agency employee can safely provide them outside of an institution; (2) the services are provided under a plan of care approved by the recipient’s attending physician, who has participated in the development of the plan of care before any private-duty nursing services were provided and has made a commitment to oversee the recipient’s care throughout the duration of the plan of care; (3) the services are required less than 24 hours per day; (4) except as provided in (e) if this section, the department has determined that, when combined with the costs of all other services provided to the recipient under 7 AAC 43 and 7 AAC 105 - 7 AAC 160, the cost of providing private-duty nursing services does not exceed the cost of institutional care for which the recipient would qualify if private-duty nursing services were not provided; and (5) a competent individual residing with the recipient has agreed to participate in caring for the recipient in accordance with the plan of care developed under (2) of this subsection. (c) If a private-duty nursing agency provides a skilled nursing service, that service must be provided by a private-duty nursing agency employee for whom the service is within the scope of that employee’s license to practice, and who provides the service while under the continued direction of the recipient’s attending physician. In this subsection, "skilled nursing service" has the meaning given in 7 AAC 125.399. (d) Private-duty nursing services include (1) assessment; (2) administration of treatment related to technological dependence; and (3) monitoring and maintaining parameters, machinery, and interventions. (e) A private-duty nursing service may not be performed by


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(1) a personal care assistant; (2) a home health aide; (3) a member of the immediate family; or (4) other members of the recipient’s household. (f) Private-duty nursing services do not include housekeeping, laundry, shopping, meal preparation, or transportation. (g) This section does not apply to specialized private-duty nursing services under 7 AAC 130.285 provided to a recipient who is receiving home and community-based waiver services. (h) The department will not pay for a private-duty nursing service (1) if requested to enable the recipient to attend school or other activities outside the home, and if the same service is not needed to enable the recipient to live successfully in the home, hospital, or nursing facility; (2) during the hours a recipient attends a child care facility; (3) for a recipient that is home schooled; (4) in excess of the private-duty nursing services already authorized by the department; (5) that is considered nurse supervision, including chart reviews, case discussions, scheduling of services, and respite care; (6) that is provided for other members of the recipient’s household; or (7) for which the department has not given prior authorization under 7 AAC 110.530. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 110.530. Private-duty nursing services; prior authorization. (a) Private-duty nursing services must be authorized by the department before services are provided. The department will not give prior authorization for private-duty nursing services for a period longer than 60 days, starting on the date the first service is to be provided. (b) To be considered by the department, a prior authorization request must originate from a private-duty nursing agency provider who submits the request in writing or electronically on a form provided by the department. The prior authorization request must (1) include the plan of care developed in accordance with 7 AAC 110.525(b)(2) and signed by the recipient’s attending physician; (2) include a nursing assessment; (3) include any supporting documentation, if applicable; (4) identify the day of actual or planned hospital or nursing facility discharge, if applicable; (5) identify any planned surgical interventions; (6) identify the number of days services are needed, not to exceed a 60-day period; and (7) identify the exact number of hours requested per day. (c) To request additional hours within a 60-day period under (a) of this section, the private-duty nursing agency must submit, before the expiration of the current 60-day period, a new request for prior authorization. The new request must include


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(1) daily nursing notes; (2) an updated plan of care signed by the recipient’s attending physician; (3) the attending physician’s order for service dated no sooner than seven days before the date of the request under this subsection; (4) recent significant clinical findings from the recipient’s attending physician; and (5) recent clinic summaries. (d) The department will approve a request for additional hours under (c) of this section, if (1) the department finds that the individual who has agreed, in accordance with 7 AAC 110.525(b)(5), to participate in caring for the recipient,

(A) needs additional training; (B) has become ill; (C) is temporarily unable to provide the required care for the recipient; or (D) is unable to provide the required care for the recipient because of a family emergency involving the caregiver;

(2) an acute episode has occurred that would otherwise require hospitalization, and the attending physician has determined that noninstitutionalized care is still safe for the recipient; or (3) the need for additional hours is medically necessary. (e) The department may increase or decrease the number of hours authorized under (c) of this section at any time based upon evidence from the attending physician that the recipient’s condition, needs, or situation has changed. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040

Article 13. Psychologist Services. Section 550. Psychologist services 7 AAC 110.550. Psychologist services. (a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing psychologist services, a provider must be an independently practicing psychologist who (1) is enrolled as a psychologist in accordance with 7 AAC 105.210; (2) has an active license to practice psychology issued by the jurisdiction in which the psychologist provides services; if services are provided in this state, the psychologist must hold an active license under AS 08.86.130 or 08.86.135; and (3) maintains records in accordance with (e) of this section. (b) Covered psychologist services are limited to medically necessary psychological testing to determine the status of the patient’s mental, intellectual, and emotional functioning. Testing services must include administration of psychodiagnostic tests, the interpretation of the results of the tests, and a written report. Testing services must be provided directly by the psychologist. Payment is limited to the following services: (1) psychological testing;


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(2) assessment of aphasia; (3) developmental testing, limited or extended; (4) neurobehavioral status examination, including assessment of thinking, reasoning, and judgment; (5) neuropsychological testing. (c) Psychologist services may be provided to a recipient who has received a referral from the recipient’s treating physician, a physician assistant, an advanced nurse practitioner, a community mental health clinic, a tribal health program, or an appropriate school official, if the referral documents the purpose for the testing, including the need to determine acuity of need, severity of symptoms, or level of impairment. (d) Psychologist services may be provided in the psychologist’s office, an outpatient clinic, an outpatient hospital, a general acute care hospital, a tribal health program, an inpatient psychiatric hospital, a residential psychiatric treatment center, or other setting appropriate for patient care. (e) To be paid by the department for services provided under this section, a psychologist must maintain a specific record for all services provided, that (1) identifies the source and reason for the referral; (2) identifies the questions and issues that the testing addressed; (3) identifies the psychological tests and techniques used; and (4) includes the interpretation of all completed and attempted tests with observations, conclusions, and recommendations. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040

Article 14. Targeted Case Management. Section 600. Targeted case management for children with disabilities 7 AAC 110.600. Targeted case management for children with disabilities. (a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing targeted case management services, a provider must (1) be enrolled as a provider of those services in accordance with 7 AAC 105.210; (2) be a grantee of the department under AS 47.20 and 7 AAC 23; and (3) provide documentation of at least one year of experience in

(A) effective work with children and families, involving a demonstrated capacity to provide all core elements of case management including assessment, development of the individualized family service plan, implementation, coordination, and reassessment; (B) coordinating and linking community medical, social, educational, and other resources as required by the target population identified in (b) of this section; (C) working with the target population identified in (b) of this section; and (D) financial management that provides documentation of service and costs.

(b) The department will pay a provider for targeted case management provided to


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a child who is eligible for infant learning program services under 7 AAC 23.080 if the child is at risk for or currently experiencing a developmental delay or disability. (c) The department will pay a provider for targeted case management provided to a child described in (b) of this section to assist and enable the child to gain access to needed medical, social, educational, developmental, and related services. Targeted case management may be delivered in person, electronically, or by telephone. (d) Targeted case management services include an intake and needs assessment that includes the ongoing systematic collection of data to determine current status and identify needs in physical, environmental, psychosocial, developmental, educational, social, behavioral, emotional, and mobility areas. A case manager who meets the requirements of (h) of this section shall collect data from a family interview, existing available records, and the needs assessment. (e) The case manager shall develop an individualized family service plan (IFSP) under AS 47.20.100 in conjunction with the family and other team members involved to identify goals, outcomes, objectives, and issues identified during the intake and needs assessment. Developing the individualized family service plan includes (1) determining activities to be completed by the case manager in support of the child and family, including obtaining appropriate health, mental health, social, educational, developmental, and transportation services to meet the child’s needs; (2) coordination and monitoring of services provided; (3) establishing and maintaining, with individuals and agencies, a referral process that avoids duplication of services to the child and family; (4) planning that identifies needs, goals, objectives, and resources in a coordinated, integrated fashion with the family and other involved agencies; (5) implementing the individualized family service plan and monitoring its status; and (6) supporting the family to reach the goals of the individualized family service plan. (f) The case manager, in consultation with the family and other team members involved, shall monitor whether the services continue to meet the child’s and family’s needs. The case manager shall make adjustments and new or additional referrals to adequately meet the child’s and family’s needs. (g) The targeted case management services must (1) assist families of eligible children in gaining access to infant learning program services under AS 47.20 and 7 AAC 23 and other medical or social services identified in the individualized family service plan; (2) coordinate and monitor the delivery of infant learning program services under AS 47.20 and 7 AAC 23 and other medical or social services that the child needs or is being provided; (3) inform families of availability of advocacy services; and (4) provide maintenance of a record of case management activities in each child’s file. (h) A case manager must (1) be an employee or contractor of the infant learning program grantee; and (2) have demonstrated knowledge and understanding about


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(A) the infant learning program under AS 47.20 and 7 AAC 23; (B) the nature and scope of Medicaid and other services available under the infant learning program; (C) the system of payment for services; (D) children eligible for the infant learning program under AS 47.20 and 7 AAC 23; (E) typical and atypical child development, family systems theory, developmentally appropriate intervention strategies, and emotional and behavioral delays and disorders; (F) interviewing skills to gather data, for development of service plans, and for individual and group communications; and (G) state and federal laws relating to child welfare and community resources.

(i) An eligible family may choose among the enrolled providers of targeted case management who provide services to the geographic area in which the family resides. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.20.070 AS 47.20.090 AS 47.07.030 AS 47.20.075 AS 47.20.100 AS 47.07.040 AS 47.20.080 AS 47.20.110 AS 47.20.060

Article 15. Telemedicine Services. Section 620. Scope 625. Telemedicine applications; limitations 630. Conditions for payment 635. Exclusions 639. Definitions 7 AAC 110.620. Scope. (a) The department will pay for medical services furnished through telemedicine applications as an alternative to traditional methods of delivering services to Medicaid recipients as provided in AS 47.07. (b) For a provider to receive payment under 7 AAC 110.620 - 7 AAC 110.639, the provider’s use of telemedicine applications must comply with the standards set out in AS 47.07, 7 AAC 43, and 7 AAC 105 - 7 AAC 160 for the medical service provided by the type of provider, including (1) provisions that affect the efficiency, economy, and quality of service; and (2) coverage limitations. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 110.625. Telemedicine applications; limitations. (a) The department will pay a provider for a telemedicine application if the provider provided the medical services through one of the following methods of delivery in the specified manner: (1) live or interactive; to be eligible for payment under this paragraph, the service must be provided through the use of camera, video, or dedicated audio conference


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equipment on a real-time basis; medical services provided by a telephone that is not part of a dedicated audio conference system or by a facsimile machine are not eligible for payment under this paragraph; (2) store-and-forward; to be eligible for payment under this paragraph, the service must be provided through the transference of digital images, sounds, or previously recorded video from one location to another to allow a consulting provider to obtain information, analyze it, and report back to the referring provider; (3) self-monitoring or testing; to be eligible for payment under this paragraph, the services must be provided by a telemedicine application based in the recipient’s home, with the provider only indirectly involved in the provision of the service. (b) The department will only make a payment for a telemedicine application if the service is limited to (1) an initial visit; (2) a follow-up visit; (3) a consultation made to confirm a diagnosis; (4) a diagnostic, therapeutic, or interpretive service; (5) a psychiatric or substance abuse assessment; (6) psychotherapy; or (7) pharmacological management services on an individual recipient basis. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 110.630. Conditions for payment. (a) The department will pay for telemedicine applications provided by a treating, consulting, presenting, or referring provider for a medical service covered by Medicaid and provided within the scope of the provider’s license. (b) A treating or consulting provider must use applicable modifiers as described in 7 AAC 145.050 for billing for a telemedicine application. (c) A presenting, referring, or consulting provider is subject to the conditions for payment that are described in 7 AAC 145.005. (d) A presenting provider is only eligible to receive Medicaid payment for a live or interactive telemedicine application as described in 7 AAC 110.625(a)(1). (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 110.635. Exclusions. (a) The department will not pay for the following services provided by telemedicine application: (1) home and community-based waiver services; (2) pharmacy services; (3) durable medical equipment services; (4) transportation services; (5) accommodation services; (6) end-stage renal disease services; (7) direct-entry midwife services; (8) private-duty nursing services;


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(9) personal care assistant services; (10) visual care, dispensing, or optician services. (b) The department will pay only for professional services for a telemedicine application of service. The department will not pay for the use of technological equipment and systems associated with a telemedicine application to render the service. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 110.639. Definitions. In 7 AAC 110.620 - 7 AAC 110.639, (1) "consulting provider" means a provider who evaluates the recipient and appropriate medical data or images through a telemedicine mode of delivery upon recommendation of the referring provider; (2) "presenting provider" means a provider who

(A) introduces a recipient to a consulting provider for examination, observation, or consideration of medical information; and (B) may assist in the telemedicine consultation;

(3) "referring provider" means a provider who evaluates a recipient, determines the need for a consultation, and arranges the services of a consulting provider for the purpose of diagnosis or treatment; (4) "telemedicine" means the practice of health care delivery, evaluation, diagnosis, consultation, or treatment, using the transfer of medical data, audio, visual, or data communications that are performed over two or more locations between providers who are physically separated from the recipient or from each other. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040

Article 16. Vision Care Services. Section 700. Vision care provider enrollment requirements 705. Vision care services 710. Complete vision examination 715. Noncovered vision care services 7 AAC 110.700. Vision care provider enrollment requirements. (a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing vision care services, a provider must (1) be enrolled as a vision care provider in accordance with 7 AAC 105.210; (2) have an active license to practice as an ophthalmologist, an optometrist, or an optician issued by the jurisdiction in which the individual provides services; if services are provided in this state the individual must be actively licensed as

(A) a physician under AS 08.64, who is certified as an ophthalmologist by the American Academy of Ophthalmology; (B) an optometrist under AS 08.72; or (C) a dispensing optician under AS 08.71.

(b) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing


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vision care services in a group practice, the group must (1) be enrolled in accordance with 7 AAC 105.210; and (2) be comprised of one or more individuals who meet the requirements of (a) of this section. (c) The department may designate one or more enrolled vision care providers for the purchase of frames or lenses through a contract for services under AS 36.30. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 AS 47.05.012 7 AAC 110.705. Vision care services. (a) The department will pay for the vision services identified in the CPT Fee Schedule for Vision Services table adopted by reference in 7 AAC 160.900, subject to the provisions of this section. (b) The department will pay for the following services for a recipient under 21 years of age: (1) one vision examination per calendar year, if the vision examination meets the requirements of 7 AAC 110.710; (2) any vision examination, in addition to the examination in (1) of this subsection, if medical justification is submitted with the providers claim for payment; (3) one complete pair of eyeglasses in each calendar year; (4) one additional complete pair of eyeglasses, if medically justified; (5) any subsequent complete pair of eyeglasses, if the department gives prior authorization based upon medical justification submitted by the provider. (c) The department will pay for the following services for a recipient 21 years of age or older: (1) one vision examination per calendar year, if the vision examination meets the requirements of 7 AAC 110.710; (2) any vision examination, in addition to the examination in (1) of this subsection, if the department gives prior authorization based upon medical justification submitted by the provider; (3) one complete pair of eyeglasses in each calendar year; (4) one additional complete pair of glasses, if the department gives prior authorization based upon medical justification submitted by the provider. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 110.710. Complete vision examination. (a) For a clinically indicated complete vision examination with a check of refractive state, the ophthalmologist or optometrist performing the examination shall (1) record a complete case history, including ocular, physical, occupational, and medical data and other pertinent information; (2) determine the best corrected visual acuity; (3) perform an external examination of the eyes and adnexa; (4) perform an internal ophthalmoscopic examination; (5) determine ocular motility and neurological integrity; (6) perform a near-point subjective examination, dynamic retinoscopy,


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and subjective refraction; and (7) if clinically indicated, perform test accommodation, convergence, and binocular coordination at far and near distances with a phorometer. (b) In addition to the requirements of (a) of this section, if contact lenses are prescribed and covered in accordance with 7 AAC 110.715, a complete vision examination must include a (1) slit-lamp evaluation; (2) fluorescein examination; and (3) diagnostic evaluation if soft lenses are prescribed. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 110.715. Noncovered vision care services. (a) The department will not pay for (1) tinted lenses, unless medically necessary for a recipient; (2) contact lenses, unless the recipient requires the lenses as a result of cataract surgery, aphakia, keratoconus, corneal degeneration, rejection of an implant, or when other medical reasons exist; (3) progressive or no-line lenses; or (4) vision therapy services for recipients 21 years of age or older. (b) Prior authorization by the department is required for tinted lenses and contact lenses. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040


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Chapter 115. Medicaid Coverage; Therapies and Related Services. Article 1. Occupational Therapy Services (7 AAC 115.100 - 7 AAC 115.120) 2. Outpatient Therapy Center Services (7 AAC 115.200 - 7 AAC 115.220) 3. Physical Therapy Services (7 AAC 115.300 - 7 AAC 115.320) 4. Speech-Language Pathology Services (7 AAC 115.400 - 7 AAC 115.420) 5. Hearing Services (7 AAC 115.500 - 7 AAC 115.549) 6. School-Based Services (7 AAC 115.600)

Article 1. Occupational Therapy Services. Section 100. Occupational therapy provider enrollment requirements 110. Occupational therapy services 120. Occupational therapy evaluation and treatment plan 7 AAC 115.100. Occupational therapy provider enrollment requirements. (a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing outpatient occupational therapy services, a provider must be an (1) occupational therapist who

(A) is enrolled in accordance with 7 AAC 105.210; (B) provides documentation of an active license to practice occupational therapy in the jurisdiction in which the individual provides services; if services are provided in this state, the individual must hold an active license under AS 08.84; and (C) if providing occupational therapy services out of state, is enrolled in the Medicaid program in the jurisdiction in which the individual provides services; or

(2) outpatient occupational therapy program operated by a tribal health program. (b) The department will pay an occupational therapist for services provided in the state by a occupational therapy assistant if the occupational therapy assistant has (1) an active license to practice as an occupational therapy assistant under AS 08.84; and (2) enrolled separately with the department as a rendering provider under 7 AAC 105.210. (c) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing occupational therapy assistant services out of state, an out-of-state occupational therapy assistant must (1) have an active license to practice as an occupational therapy assistant in the jurisdiction in which services are provided; (2) provide proof of enrollment as a Medicaid provider in the jurisdiction in which the services are provided or documentation from that jurisdiction showing that occupational therapy assistants are not enrolled as Medicaid providers in that jurisdiction; and (3) be enrolled separately with the department as a rendering provider under 7 AAC 105.210. (Eff. 2/1/2010, Register 193)


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Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 115.110. Occupational therapy services. (a) The department will pay for occupational therapy services and supplies (1) that are identified in the CPT Fee Schedule for Occupational Therapy Services table and HCPC Fee Schedule for Occupational Therapy Services table, adopted by reference in 7 AAC 160.900; and (2) if those services, except the initial evaluation, are

(A) prescribed by a physician, an advanced nurse practitioner, or a physician assistant and the services prescribed are within the scope of the practitioner's license; (B) within the scope of practice of an occupational therapist or occupational therapy assistant; (C) provided by or under the direction of an occupational therapist who is enrolled under 7 AAC 105 - 7 AAC 160; (D) provided in accordance with the initial evaluation conducted under 7 AAC 115.120(a) and treatment plan developed by the occupational therapist under 7 AAC 115.120(b); and (E) documented in a progress note to include start and stop times for time-based billing codes used as provided in the Healthcare Common Procedure Coding System (HCPCS), adopted by reference in 7 AAC 160.900.

(b) The department will not pay for occupational therapy services for an individual 21 years of age or older that are for maintenance of bodily function, swimming therapy, habilitation, or weight loss. (c) The department will not pay for the services provided by an occupational therapist aide. (d) The department will pay for maintenance occupational therapy services related to conditions caused by developmental disabilities or developmental delay provided to a recipient under 21 years of age if the services prevent a condition from worsening or the development of an additional health problem. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 115.120. Occupational therapy evaluation and treatment plan. (a) Before initiating treatment, the occupational therapist shall conduct an initial evaluation of the recipient that includes an assessment of the (1) recipient's significant past medical history; (2) diagnosis and prognosis, if established, and the extent to which the recipient is aware of the diagnosis and prognosis; (3) prescribing health care practitioner orders, if any; (4) rehabilitation goals and potential for achievement; (5) contraindications, if any; (6) summary of any known prior treatment; and (7) goals of any maintenance occupational therapy as described in 7 AAC 115.110(d). (b) After conducting the initial evaluation of a recipient, the occupational


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therapist must establish a written treatment plan. The plan must specify the diagnosis, the anticipated treatment goals, and the type, amount, frequency, and duration of each service. No more than 14 days after the plan is developed or changes are made to service levels, the treatment plan must be signed by the health care practitioner that prescribed the services as required under 7 AAC 115.110(a)(2)(A). The department will not pay for services provided more than 14 days after the treatment plan is developed or changes are made to service levels if the treatment plan has not been signed. (c) After the treatment plan is signed as required under (b) of this section, the health care practitioner that prescribed the services shall review and sign the treatment plan as often as the recipient's medical condition requires or if changes are made to the treatment plan, and no less often than (1) every six months for recipients under three years of age; (2) annually for recipients three years of age or older and under 21 years of age; (3) every 30 days for recipients 21 years of age or older. (d) The occupational therapist shall record in the recipient's clinical record any changes made to the treatment plan. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040

Article 2. Outpatient Therapy Center Services. Section 200. Outpatient therapy center enrollment requirements 210. Outpatient therapy center services 220. Outpatient therapy center evaluation and treatment plan 7 AAC 115.200. Outpatient therapy center enrollment requirements. To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing physical therapy, occupational therapy, speech-language pathology services, or an combination of those services, an outpatient therapy center must be (1) enrolled in as an outpatient therapy center provider in accordance with 7 AAC 105.210; (2) certified by the department under 42 C.F.R. 488.11 and 42 C.F.R. 488.26 to be in compliance with 42 C.F.R. 485.701 - 485.729 and, for occupational therapy made applicable by 42 U.S.C. 1395x(g), by the jurisdiction in which services are provided; 42 C.F.R. 488.11, 42 C.F.R. 488.26, and 42 C.F.R. 485.701 - 485.729 are adopted by reference in 7 AAC 160.900; and (3) if providing outpatient therapy center services out of state, enrolled as an outpatient therapy center provider in the jurisdiction in which services are provided. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 115.210. Outpatient therapy center services. (a) The department will pay for the physical therapy, occupational therapy, and speech-language pathology services and supplies identified in the CPT Fee Schedule for Outpatient Therapy Services table and HCPC Fee Schedule for Outpatient Therapy Services table, adopted by reference in 7 AAC 160.900, if those services and supplies, except the initial evaluation,


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are (1) prescribed by a physician, an advanced nurse practitioner, or a physician assistant who may prescribe those services and supplies within the scope of the practitioner’s license; (2) delivered by a physical therapist, an occupational therapist, or a speech-language pathologist who holds an active license to practice issued by the jurisdiction in which services are provided and who provides direct services only within the scope of that license; if services are provided in this state the individual must hold an active license under AS 08; and (3) provided in accordance with the initial evaluation and treatment plan developed under 7 AAC 115.220. (b) The department will pay for the services of an occupational therapy assistant, physical therapy assistant, or speech-language pathologist assistant if those services are (1) provided by an assistant who holds an active license to practice in the jurisdiction in which services are provided; if the services are provided in this state the individual must hold an active license under AS 08.84 or AS 08.11, whichever applies; (2) performed in accordance with the requirements of AS 08.11.042, 12 AAC 54.510, 12 AAC 54.810, or 12 AAC 54.820, whichever applies, or the equivalent requirements in the jurisdiction in which services are provided; and (3) billed through the supervising therapist who meets the requirements of (a)(2) of this section. (c) The department will not pay for the services provided by a occupational therapy aide, physical therapy aide, or a speech-language pathologist aide. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 115.220. Outpatient therapy center evaluation and treatment plan. (a) Before or at the time of initiating treatment, the outpatient therapy center shall conduct an initial evaluation of the recipient that includes an assessment of the (1) recipient’s significant past medical history; (2) diagnosis and prognosis, if established, and the extent to which the recipient is aware of the diagnosis and prognosis; (3) prescribing health care practitioner orders, if any; (4) rehabilitation goals and potential for achievement; (5) contraindications, if any; and (6) summary of any prior treatment, if known. (b) After conducting the initial evaluation of a recipient, the outpatient therapy center must establish a written treatment plan. The plan must specify the diagnosis, anticipated treatment goals, and the type, amount, frequency, and duration of each service. No more than 14 days after the plan is developed or changes are made to service levels, the treatment plan must be signed by the health care practitioner that prescribed the services as required under 7 AAC 115.210(a)(1). The department will not pay for services provided more than 14 days after the treatment plan is developed or changes are made to service levels if the treatment plan has not been signed. (c) After the treatment plan is signed as required under (b) of this section, the health care practitioner that prescribed the services shall review and sign the treatment


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plan as often as the recipient's medical condition requires or if changes are made to the treatment plan, and no less often than (1) every 30 days for recipients 21 years of age or older; (2) every six months for recipients under three years of age; or (3) annually for recipients at least three years of age, but less than 21 years of age. (d) An outpatient therapy center must record in the recipient’s clinical record any changes made to the treatment plan. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040

Article 3. Physical Therapy Services. Section 300. Physical therapy provider enrollment requirements 310. Physical therapy services 320. Physical therapy evaluation and treatment plan 7 AAC 115.300. Physical therapy provider enrollment requirements. (a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing outpatient physical therapy services, the individual must be (1) a physical therapist who

(A) is enrolled in accordance with 7 AAC 105.210; (B) provides documentation of an active license to practice physical therapy in the jurisdiction in which the individual provides services; if services are provided in this state, the individual must hold an active license under AS 08.84; and (C) if providing physical therapy services out of state, is enrolled in the Medicaid program in the jurisdiction in which the individual provides service; or

(2) an outpatient physical therapy program operated by a tribal health program. (b) The department will pay a physical therapist for services provided in the state by a physical therapy assistant if the physical therapy assistant has (1) an active license to practice as a physical therapy assistant under AS 08.84; and (2) enrolled separately with the department as a rendering provider under 7 AAC 105.210. (c) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing physical therapy assistant services out of state, an out-of-state physical therapy assistant must (1) have an active license to practice as a physical therapy assistant in the jurisdiction in which services are provided; (2) provide proof of enrollment as a Medicaid provider in the jurisdiction in which the services are provided or documentation from that jurisdiction that physical therapy assistants are not enrolled as Medicaid providers in that jurisdiction; and (3) be enrolled separately with the department as a rendering provider under 7 AAC 105.210. (Eff. 2/1/2010, Register 193)


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Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 115.310. Physical therapy services. (a) Payment for physical therapy services is limited to (1) evaluations; (2) physical agents; (3) massage and manipulation; (4) therapeutic exercise; (5) hydrotherapy; and (6) other forms of treatment for rehabilitation and restoration of normal bodily functions following acute physical illness or acute physical trauma. (b) The department will pay for physical therapy services and supplies (1) that are identified in the CPT Fee Schedule for Independent Physical Therapists table and HCPC Fee Schedule for Independent Physical Therapists table, adopted by reference in 7 AAC 160.900; and (2) if those services, except the initial evaluation, are

(A) prescribed by a physician, an advanced nurse practitioner, or a physician assistant and the services prescribed are within the scope of the practitioner's license; (B) within the scope of practice of a physical therapist or physical therapy assistant; (C) provided by or under the direction of a physical therapist who is enrolled under 7 AAC 105 - 7 AAC 160; (D) provided in accordance with the initial evaluation conducted under 7 AAC 115.320(a) and the treatment plan developed by the physical therapist under 7 AAC 115.320(b); and (E) documented in a progress note to include start and stop times for time-based billing codes used as provided in the Healthcare Common Procedure Coding System (HCPCS), adopted by reference in 7 AAC 160.900.

(c) Maintenance physical therapy services related to conditions caused by developmental disabilities or developmental delay to a recipient under 21 years of age will be paid if the services prevent a condition from worsening or the development of an additional health problem. (d) The department will not pay for physical therapy services that are for maintenance of bodily function, swimming therapy, physical fitness, habilitation, or weight loss. (e) The department will not pay for the services provided by a physical therapist aide. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 115.320. Physical therapy evaluation and treatment plan. (a) Before initiating treatment, the physical therapist shall conduct an initial evaluation of the recipient that includes an assessment of the (1) recipient's significant past medical history; (2) diagnosis and prognosis, if established, and the extent to which the recipient is aware of the diagnosis and prognosis;


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(3) prescribing health care practitioner orders, if any; (4) rehabilitation goals and potential for achievement; (5) goals of any maintenance physical therapy as described in 7 AAC 115.310(c); (6) contraindications, if any; and (7) summary of any known prior treatment. (b) After conducting the initial evaluation of a recipient, the physical therapist must establish a written treatment plan. The plan must specify the diagnosis, the anticipated treatment goals, and the type, amount, frequency, and duration of each service. No more than 14 days after the plan is developed or changes are made to service levels, the treatment plan must be signed by the health care practitioner that prescribed the services as required under 7 AAC 115.310(b)(2)(A). The department will not pay for services provided more than 14 days after the treatment plan is developed or changes are made to service levels if the treatment plan has not been signed. (c) After the treatment plan is signed as required under (b) of this section, the health care practitioner that prescribed the services shall review and sign the treatment plan as often as the recipient's medical condition requires or if changes are made to the treatment plan, and no less often than (1) every six months for recipients under three years of age; (2) annually for recipients three years of age or older and under 21 years of age; (3) every 30 days for recipients 21 years of age or older. (d) The physical therapist must record in the recipient's clinical record any changes made to the treatment plan. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040

Article 4. Speech-Language Pathology Services. Section 400. Speech-language pathology enrollment requirements 410. Speech-language pathology services 420. Speech-language evaluation and treatment plan 7 AAC 115.400. Speech-language pathology enrollment requirements. (a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing speech-language pathology services, a provider must be (1) a speech-language pathologist who

(A) is enrolled in accordance with 7 AAC 105.210; (B) provides documentation of an active license to practice speech-language pathology in the jurisdiction in which the individual provides services; if services are provided in this state, the individual must hold an active license under AS 08.11; and (C) if providing speech-language pathology services out of state, is enrolled in the Medicaid program in the jurisdiction in which the individual provides services; or

(2) an outpatient speech therapy program operated by a tribal health program.


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(b) The department will pay a speech-language pathologist for services provided in the state by a (1) speech-language pathology assistant if the speech-language pathology assistant

(A) has an active registration to practice as a speech-language pathology assistant under AS 08.11.043; and (B) has enrolled separately with the department as a rendering provider under 7 AAC 105.210; or

(2) speech-language pathologist described in AS 08.11.025(b)(3), if the speech-language pathologist

(A) has an active temporary license to practice as a speech-language pathologist under AS 08.11.025; and (B) has enrolled separately with the department as a rendering provider under 7 AAC 105.210.

(c) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing speech-language pathology services, an out-of-state (1) speech-language pathology assistant must

(A) have an active registration to practice as a speech-language pathology assistant in the jurisdiction in which services are provided; (B) provide proof of enrollment as a Medicaid provider in the jurisdiction in which services are provided or documentation from that jurisdiction that speech-language pathology assistants are not enrolled as Medicaid providers in that jurisdiction; and (C) be enrolled separately with the department as a rendering provider;

(2) speech-language pathologist described in AS 08.11.025(b)(3) must (A) have an active temporary license to practice as a speech-language pathologist in the jurisdiction in which services are provided; (B) provide proof of enrollment as a Medicaid provider in the jurisdiction in which services are provided or documentation from that jurisdiction that speech-language pathologists holding a temporary license are not enrolled as Medicaid providers in that jurisdiction; and (C) be enrolled separately with the department as a rendering provider under 7 AAC 105.210. (Eff. 2/1/2010, Register 193)

Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 115.410. Speech-language pathology services. The department will pay for speech-language pathology services and supplies (1) that are identified in the CPT Fee Schedule for Speech Pathologists table and HCPC Fee Schedule for Speech Pathologists table, adopted by reference in 7 AAC 160.900; and (2) if those services and supplies, except the initial evaluation, are

(A) prescribed by a physician, an advanced nurse practitioner, or physician assistant and the services and supplies prescribed are within the scope of the practitioner's license; (B) within the scope of practice of an speech-language pathologist


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or speech-language pathology assistant; (C) provided by or under the direction of a speech-language pathologist who is enrolled under 7 AAC 105 - 7 AAC 160; (D) provided in accordance with the initial evaluation conducted under 7 AAC 115.420(a) and treatment plan developed by the speech-language pathologist under 7 AAC 115.420(b); and (E) documented in a progress note to include start and stop times for time-based billing codes used as provided in the Healthcare Common Procedure Coding System (HCPCS), adopted by reference in 7 AAC 160.900. (Eff. 2/1/2010, Register 193)

Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 115.420. Speech-language evaluation and treatment plan. (a) Before initiating treatment, the speech-language pathologist shall conduct an initial evaluation of the recipient that includes an assessment of the (1) recipient's significant past medical history; (2) diagnosis and prognosis, if established, and the extent to which the recipient is aware of the diagnosis and prognosis; (3) prescribing health care practitioner orders, if any; (4) rehabilitation goals and potential for achievement; (5) contraindications, if any; and (6) summary of any known prior treatment. (b) After conducting the initial evaluation of a recipient, the speech-language pathologist must establish a written treatment plan. The plan must specify the diagnosis, the anticipated treatment goals, and the type, amount, frequency, and duration of each service. No more than 14 days after the plan is developed or changes are made to service levels, the treatment plan must be signed by the health care practitioner that prescribed the services as required under 7 AAC 115.410(2)(A). The department will not pay for services provided more than 14 days after the treatment plan is developed or changes are made to service levels if the treatment plan has not been signed. (c) After the treatment plan is signed as required under (b) of this section, the health care practitioner that prescribed the services shall review and sign the treatment plan as often as the recipient's medical condition requires or if changes are made to the treatment plan, and no less often than (1) every six months for recipients under three years of age; (2) annually for recipients three years of age or older and under 21 years of age; (3) every 30 days for recipients 21 years of age or older. (d) The speech-language pathologist must record in the recipient's clinical record any changes made to the treatment plan. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040


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Article 5. Hearing Services. Section 500. Hearing services provider enrollment 510. Audiologist services 520. Hearing aid dealer services 530. Hearing services and items 540. Prior authorization of hearing services and items 549. Definitions 7 AAC 115.500. Hearing services provider enrollment. (a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing hearing services, the individual must (1) be enrolled in accordance with 7 AAC 105.210; and (2) have an active license to practice as an audiologist or hearing aid dealer issued by the jurisdiction in which the individual provides services; if services are provided in this state, the individual must hold an active license as an audiologist under AS 08.11 or a hearing aid dealer under AS 08.55. (b) The department may designate one or more enrolled hearing services providers for the purchase of hearing items through a contract for services under AS 36.30. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 AS 47.05.015 7 AAC 115.510. Audiologist services. (a) Subject to the requirements of 7 AAC 115.500 - 7 AAC 115.549 and 7 AAC 145.340, the department will pay an audiologist for hearing services and hearing items identified in 7 AAC 115.530 that are rendered within the scope of the audiologist’s license. (b) The department will pay an audiologist for cochlear implantation-related services, including (1) a preliminary assessment; (2) programming of the cochlear device; (3) adjustments; (4) recipient education; (5) auditory rehabilitation; and (6) treatment sessions. (c) The department will not pay separately for external cochlear implant parts that are provided as part of the initial surgical implanting of a cochlear device. (d) The department will pay an audiologist for external cochlear implant replacement parts if they are prescribed by an audiologist, otologist, otolaryngologist, or a physician working within the scope of the physician’s license and training. External cochlear implant parts are a (1) microphone; (2) speech processor; and (3) transmitter. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040


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7 AAC 115.520. Hearing aid dealer services. (a) Subject to the requirements of 7 AAC 115.500 - 7 AAC 115.549 and 7 AAC 145.340, the department will pay a hearing aid dealer for the hearing services and hearing items identified in 7 AAC 115.530 (1) that are provided within the scope of the hearing aid dealer’s license; and (2) if the hearing item is a hearing aid,

(A) the hearing aid is prescribed by a physician; and (B) the requirements of AS 08.55.060(a) and (b) are met.

(b) The department will not pay a hearing aid dealer (1) if the recipient has waived the hearing evaluation under AS 08.55.060(c); or (2) for a hearing test or diagnostic procedure designed to determine the cause of a hearing impairment. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 115.530. Hearing services and items. (a) The department will pay a hearing services provider for providing a hearing service or hearing item, if that hearing service or hearing item is (1) prescribed by an audiologist, otologist, otolaryngologist, or a physician, except as provided in 7 AAC 115.520(a)(2); and (2) identified by the prescriber in (1) of this subsection as

(A) medically necessary to alleviate a disability caused by a hearing impairment; and (B) the least costly alternative that fits the recipient’s medical need.

(b) The department will pay for a hearing service or hearing item subject to the following conditions and limits: (1) a hearing services provider must include a manufacturer’s warranty of no less than one year from the original purchase date of all hearing items; (2) the department will pay for no more than one hearing aid, per ear, per recipient, per three calendar years; the department will not pay for the following hearing aid supplies included with a hearing aid purchased under this paragraph:

(A) a single cord; (B) a Y-cord; (C) a harness; (D) a new receiver; (E) a bone-conduction receiver with headband;

(3) the department will pay one fitting fee per ear, per purchase or rental of a hearing aid; each fitting fee paid under this paragraph includes payment for a minimum of three follow-up visits by the recipient to the hearing services provider to have the hearing aid checked for proper functioning; (4) the department will pay one dispensing fee per ear, per purchase or rental of a hearing aid for the life of that hearing aid under normal use or for the duration of the rental contract; the dispensing fee covers the following:

(A) repair; (B) replacement parts;


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(C) periodic cleaning; (D) labor.

(c) For a recipient under 21 years of age, the department will pay (1) separately for an unlimited number of ear mold impressions and ear molds; (2) for an unlimited number of repairs of a hearing aid if

(A) the hearing aid warranty is no longer in effect; and (B) the hearing services provider has not already been paid a dispensing fee under (b)(4) of this section;

(3) no more than two replacements of a lost hearing aid if (A) the hearing aid warranty is no longer in effect; (B) the hearing aid was lost no more than three years after the original date of purchase; and (C) a written explanation of how the hearing aid was lost is submitted by the hearing services provider with the provider’s claim for payment; the written explanation must be signed by the recipient or, if the recipient is a minor, recipient’s parent or guardian;

(4) for no more than two replacements of a broken hearing aid if (A) the hearing aid warranty is no longer in effect; (B) the hearing aid was broken no more than three years after the original date of purchase; and (C) the hearing services provider has certified in writing that the hearing aid cannot be repaired or that the cost of repairs would exceed the maximum payment rate for repairing the hearing aid.

(d) For a recipient 21 years of age or older, the department will pay (1) separately for no more than two ear mold impressions and two ear molds, per ear, per three calendar years; (2) no more than two repairs of a hearing aid if

(A) the hearing aid warranty is no longer in effect; and (B) the hearing services provider has not already been paid a dispensing fee under (b)(4) of this section;

(3) no more than one replacement of a lost hearing aid if (A) the hearing aid warranty is no longer in effect; (B) the hearing aid was lost no more than three years after the original date of purchase; and (C) a written explanation of how the hearing aid was lost is submitted by the hearing services provider with the provider’s claim for payment; the written explanation must be signed by the recipient;

(4) for no more than one replacement of a broken hearing aid if (A) the hearing aid warranty is no longer in effect; (B) the hearing aid was broken no more than three years after the original date of purchase; and (C) the hearing services provider has certified in writing that the hearing aid cannot be repaired or that the cost of repairs would exceed the maximum payment rate for repairing the hearing aid.

(e) If the department is paying for the replacement of a hearing aid under this


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section and the hearing aid manufacturer’s warranty is in effect, the department will pay the deductible fee up to the maximum amount set in 7 AAC 145.340. The hearing services provider must submit a copy of the manufacturer’s warranty with each claim to document the amount of the deductible. (f) The department will pay a hearing services provider for any type of monaural or binaural hearing aid that is worn in or behind the ear. (g) The department will pay for batteries, subject to the following limits: (1) 20 hearing aid batteries per month up to 160 per year, per recipient; if the batteries are for a recipient’s hearing aid that the department did not purchase, the hearing services provider must record in the recipient’s record the manufacturer’s serial number and the purchase date of the hearing aid; (2) 30 cochlear implant alkaline batteries per month; (3) 55 cochlear implant zinc air batteries per month. (h) The department will pay a hearing services provider for the reasonable and necessary costs of delivering a hearing item, not to exceed the amount set in 7 AAC 145.340, as follows: (1) the cost on invoice of delivering a hearing item from the hearing services provider to a recipient who resides outside the municipality where the business of the hearing services provider is located if

(A) the hearing item is unavailable in the municipality in which the recipient resides; and (B) the hearing services provider submits a receipt for the delivery cost with the claim for payment;

(2) the cost on invoice of delivering a hearing item from the manufacturer to the hearing services provider following the manufacturer’s repair of that hearing item if the hearing services provider submits with the claim for payment a copy of the manufacturer’s invoice showing the cost of delivery to the hearing services provider. (i) When a damaged hearing item is no longer covered under the manufacturer’s warranty, the department will pay a hearing services provider separately for the labor necessary to (1) assess a damaged hearing item; and (2) repair a damaged hearing item. (j) The department will pay for the labor, repair, or replacement cost of a hearing item only if the repair or replacement is necessary for the hearing item to function as intended. A claim submitted to the department for the labor, repair, or replacement of a hearing item must include (1) a statement signed by the recipient or the recipient’s representative that describes the cause for and nature of the repair; (2) a description of the hearing item being repaired and its serial number, if available; (3) the beginning and end dates of warranty coverage, if available; and (4) documentation for labor charges that includes the amount of time spent on the repair, rounded up to the nearest quarter hour, and the hourly rate charged for the repair. (k) The department will not pay for labor, repair, or replacement costs if (1) the hearing item is covered under a manufacturer’s or supplier’s


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warranty; (2) the hearing item needs repair because of a manufacturer’s defect; or (3) the labor, repair, or replacement has already been paid for as a dispensing fee under (b)(4) of this section. (l) The department will not pay for hearing item rental or a rent-to-purchase arrangement if the rental price would be more expensive than the purchase price. The department will pay a hearing services provider for hearing item rental or a rent-to-purchase arrangement as follows: (1) for a rental period that is 30 days or longer, the department will pay a monthly rental fee that is equal to 10 percent of the allowed purchase price, as calculated under 7 AAC 145.340; (2) for a rental period that is less than 30 days, the department will pay an amount equal to the monthly rental fee divided by the number of days in the month, times the number of days in the rental period; (3) the department will not pay a rental fee for a rental period that exceeds 12 months of continuous use; if the length of need is more than 12 months of continuous use, the prescriber must administer another hearing assessment and request prior authorization for the purchase of a new hearing item; the department will pay the difference between the allowed purchase price and the total monthly rental fees already paid by the department if the hearing services provider

(A) transfers ownership of the hearing item, including any warranty, to the recipient for whom it was rented; and (B) replaces the rented hearing item with a new hearing instrument if the rented hearing item was previously used by anyone other than the recipient before it was rented to the recipient;

(4) before the total rental fee payments equal the allowed purchase price, the department will not separately pay the cost of labor, repairs, and maintenance; labor, repairs, and maintenance must be included in the rental fee and must be documented in the rental agreement; (5) when total rental payments reach the allowed purchase price of a new hearing item, the department will pay the cost of labor, repair, and maintenance after 60 days or when the warranty expires, whichever is later. (m) The department will not pay a hearing services provider separately for the provider’s administrative expenses. The following costs are considered administrative expenses and are included in the payment for the hearing item: (1) telephone responses to questions; (2) mileage; (3) travel expenses; (4) travel time; (5) equipment set up; (6) installation; (7) office inventory supply; (8) orientation and training regarding the proper use of equipment. (n) The department will not pay for items identified as assistive listening devices in the Healthcare Common Procedure Coding System (HCPCS), adopted by reference in 7 AAC 160.900, including the following:


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(1) a telephone amplifier; (2) an alerter; (3) a television amplifier; (4) a television caption decoder; (5) a telecommunications device for the deaf (TDD); (6) a device for use with a cochlear implant. (o) The department will not pay a hearing services provider for charges submitted for adjustments, labor, repairs, or replacement parts for a previously purchased hearing item when the department has purchased a newer like item. (p) Based upon the medical documentation provided for prior authorization, the department will pay for a recipient’s use of a hearing item on a trial basis when a trial period is not covered by the manufacturer, if supported by the medical documentation submitted by the hearing services provider under 7 AAC 115.540. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 115.540. Prior authorization of hearing services and items. (a) A provider must obtain prior authorization from the department before the department will pay for (1) the purchase of a replacement cochlear implant part or rechargeable lithium ion battery; (2) the rental of hearing aids; (3) the purchase of a hearing item that exceeds a limit under 7 AAC 115.530; (4) a payment request that exceeds the maximum allowable payment for a hearing item; (5) a customized hearing aid; (6) a monaural hearing aid or binaural hearing aid for which a payment rate has not been established; (7) the purchase of the following hearing services or hearing items identified as miscellaneous in the Healthcare Common Procedure Coding System (HCPCS), adopted by reference in 7 AAC 160.900:

(A) a personal FM system, for a recipient under 21 years of age with hearing loss diagnosed by an audiologist licensed under AS 08.11; (B) a hearing aid; (C) a hearing aid accessory; (D) a hearing aid supply; (E) a hearing service.

(b) To request prior authorization, a hearing services provider must (1) complete a certificate of medical necessity form provided by the department; (2) include documentation that a licensed health care practitioner working within the scope of that practitioner’s license has

(A) determined that the service is medically necessary; (B) conducted a clinical assessment of the recipient; and (C) prepared a treatment plan.


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(c) In addition to the requirements of (b) of this section, a hearing services provider requesting prior authorization for a payment amount that exceeds the maximum allowable payment must include a written statement that the recipient’s condition requires the more costly item or service. (d) In addition to the requirements of (b) of this section, a hearing services provider requesting prior authorization for replacement of a hearing item under 7 AAC 115.530(j) must show evidence satisfactory to the department that the item (1) is necessary to replace a hearing item that is under repair; (2) is necessary to replace a hearing item that has been in continuous use by the recipient for the item’s reasonable useful lifetime; or (3) is not covered by a manufacturer’s warranty and is determined to be damaged as the result of a manufacturing defect or owner’s negligence. (e) The department will review a request for prior authorization on an individual basis. Using the data available from an auditory assessment of the recipient, the department will consider the (1) degree of the recipient’s hearing loss; (2) type of recipient’s hearing loss; (3) configuration of the recipient’s hearing loss; and (4) management and treatment plan prepared. (f) In this section, "miscellaneous" means a hearing item or hearing service listed in the Healthcare Common Procedure Coding System (HCPCS), adopted by reference in 7 AAC 160.900, that is (1) described as "miscellaneous," "not otherwise classified," or "not otherwise specified"; or (2) without a specific description or identifier. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 Editor’s note: The certificate of medical necessity referred to in 7 AAC 115.540(b) may be obtained from the Department of Health and Social Services, Division of Health Care Services, 4501 Business Park Boulevard, Suite 24, Anchorage, Alaska 99503-7167; Internet address: http://www.hss.state.ak.us/dhcs. 7 AAC 115.549. Definitions. In 7 AAC 115.500 – 7 AAC 115.549, (1) "customized hearing aid" means a hearing aid that is uniquely constructed or substantially modified to fit the anatomy of a specific recipient; (2) "hearing aid" has the meaning given in AS 08.55.200; (3) "hearing aid accessory" means an accessory that is

(A) not included with the dispensing of a hearing aid; (B) not physically connected to the hearing aid when the hearing aid is being worn by the individual; and (C) used to prolong the life of the hearing aid by providing maintenance, hygiene, or safekeeping.

(4) "hearing aid supply" means a supply, including a battery and replacement part, that is

(A) provided separately from the initial dispensing of a hearing aid;


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(B) physically connected to the hearing aid when the hearing aid is being worn by the individual; and (C) necessary to keep the hearing aid functioning;

(5) "hearing item" means a hearing aid, hearing aid supply, hearing aid accessory, customized hearing aid, cochlear implant battery, or cochlear implant part. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040

Article 6. School-Based Services. Section 600. School-based services 7 AAC 115.600. School-based services. (a) The department will enroll an in-state school district as a Medicaid provider of school-based services if the school district meets the requirements of AS 47.07 and 7 AAC 105 - 7 AAC 160 and enters into an agreement with the department as required by AS 47.07.063. (b) The school district shall submit each request for payment for a school-based service using the provider code number assigned to the school district at enrollment. (c) The department will pay the cost of an evaluation, screening, or assessment of a Medicaid-eligible child’s need for a school-based service only if the outcome indicates the child’s need for services included in the individualized education plan described in (d) of this section. (d) The department will pay for school-based services for a Medicaid-eligible child if the individualized education plan developed for the child under AS 14.30.278 specifies the services that the school district is seeking payment for, each health condition to be addressed, the anticipated treatment goals, and the type, amount, frequency, and duration of each service to be offered. Any change to a plan that adds, eliminates, or alters a service, material, or supply described under this section must be documented in the Medicaid-eligible child’s clinical record by or under the direction of a physician, a physician’s assistant, an advanced nurse practitioner, a physical therapist, an occupational therapist, a speech-language pathologist, an audiologist, a psychologist or psychological associate, a behavioral health professional, a behavioral health associate, or other health care provider who is (1) acting within the scope of that health care provider’s

(A) license under AS 08; or (B) training and experience, if the health care provider is a psychologist or psychological associate described in (h)(7)(A)(ii) of this section, a behavioral health professional, or a behavioral health associate; and

(2) familiar with the child’s plan, health condition, and treatment history. (e) In addition to meeting the requirements for provider records in 7 AAC 105.230 and AS 47.07.063(b), and before the department will pay for school-based services, the school district must assure that each Medicaid-eligible child’s clinical record includes (1) documentation of the relationship of the service provided to the child’s achievement of individualized education plan goals and objectives; and (2) on each page of service documentation, the Medicaid-eligible child’s


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recipient identification number and at least one other item of unique identification for the Medicaid-eligible child who received the service; for the purposes of this paragraph, "item of unique identification" includes the child’s name, date of birth, and student identification number assigned by the school district. (f) Nothing in this section precludes a private enrolled provider from furnishing the same service to the same child at a different time on the same day that the child was furnished a school-based service, if the applicable requirements of 7 AAC 105 - 7 AAC 160 are otherwise met. (g) Subject to the requirements of AS 47.07.063(a), the department will pay a school district for the following school-based services furnished in accordance with 7 AAC 105 - 7 AAC 160 to a Medicaid-eligible child with a disability, and for materials and supplies provided to the child in the course of performing the services, if those materials and supplies are furnished in accordance with 7 AAC 105 - 7 AAC 160: (1) physical therapy services furnished by or under the direction of a physical therapist licensed under AS 08.84, and practicing in accordance with 7 AAC 115.300 - 7 AAC 115.320, regardless of whether that person is enrolled under 7 AAC 115.300; (2) occupational therapy services furnished by or under the direction of an occupational therapist licensed under AS 08.84, and practicing in accordance with 7 AAC 115.100 - 7 AAC 115.120, regardless of whether that person is enrolled under 7 AAC 115.100; (3) speech-language pathology services furnished by or under the direction of a speech-language pathologist who

(A) meets the requirements of 42 C.F.R. 440.110(c) or is licensed under AS 08.11; and (B) is practicing in accordance with 7 AAC 115.400 - 7 AAC 115.420, regardless of whether that person is enrolled under 7 AAC 115.400;

(4) hearing services furnished by or under the direction of an audiologist licensed under AS 08.11, and practicing in accordance with 7 AAC 115.500 - 7 AAC 115.549, regardless of whether that person is enrolled under 7 AAC 115.500; (5) behavioral health services including

(A) the following services furnished by a behavioral health associate or behavioral health professional:

(i) emotional support assistance to help a child process emotions during periods of elevated stress; (ii) behavior management education that teaches behavior management, modification, and redirection techniques to elicit positive behaviors with families, groups, and individuals;

(B) the following services furnished by a behavioral health professional:

(i) crisis response services that include short-term interventions to prevent harm, build coping skills, develop mechanisms for positive self-care, and stabilize a child or family in acute distress; (ii) behavior modification assistance using counseling techniques to assist in modifying behavior to individuals and groups; (iii) functional behavioral assessments to assess a child’s


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behavior; (iv) psychoeducational services designed to help a child develop or improve specific self-care skills and engage in age-appropriate social behavior; and

(C) services furnished by a psychologist or a psychological associate, including

(i) testing a child’s psychological, cognitive, and emotional functioning; and (ii) interpreting a child’s psychological, cognitive, emotional, and behavioral assessment results;

(6) medication services furnished by a nurse licensed under AS 08.68, including medication administration, direct observation, training, and support. (h) In this section, (1) "child with a disability" has the meaning given in AS 14.30.350; (2) "individualized education plan" and "plan" means the plan developed for a Medicaid-eligible child with a disability through an individualized education program described in AS 14.30.278; (3) "school-based service" means a service identified in this section that is furnished in accordance with AS 47.07 and 7 AAC 105 - 7 AAC 160 by a school district to a Medicaid-eligible child with a disability; (4) "school district" has the meaning given in AS 47.07.063; (5) "behavioral health associate" means a person who has less than a master’s degree in psychology, social work, counseling, or a related field with specialization or experience in working with children experiencing behavioral, physical, and emotional disabilities, and is working within the scope of the person’s training and experience; "behavioral health associate" does not include a person employed as a teacher; (6) "behavioral health professional" means a person who has a master’s degree in psychology, social work, counseling, or a related field with specialization or experience in working with children experiencing behavioral, physical, and emotional disabilities, and is working within the scope of the person’s training and experience; "behavioral health professional" does not include a person employed as a teacher; (7) "psychologist or psychological associate"

(A) means a psychologist or psychological associate (i) licensed under AS 08.86 and working within the scope of the person’s license; or (ii) with a special services certificate (Type C) under 4 AAC 12 endorsed in "school psychology," who is employed by the school district and working within the scope of the person’s training and experience; and

(B) does not include a person employed as a teacher by the school district. (Eff. 2/1/2010, Register 193)

Authority: AS 47.05.010 AS 47.07.040 AS 47.07.063 AS 47.07.030


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Chapter 120. Medicaid Coverage; Prescription Drugs and Medical Supplies; Durable Medical Equipment; Transportation Services.

Article 1. Prescription Drugs and Medical Supplies (7 AAC 120.100 - 7 AAC 120.140) 2. Durable Medical Equipment and Medical Supplies; Related Services (7 AAC 120.200

- 7 AAC 120.299) 3. Transportation and Accommodation Services (7 AAC 120.400 - 7 AAC 120.490)

Article 1. Prescription Drugs and Medical Supplies. Section 100. Provider requirements 110. Drug coverage 120. Drug use review 130. Prior authorization and limitations on prescribed drugs 140. Preferred drug list 7 AAC 120.100. Provider requirements. (a) A provider seeking payment for providing pharmacy services under 7 AAC 43 or 7 AAC 105 - 7 AAC 160 must be (1) enrolled as a pharmacist or retail pharmacy in accordance with 7 AAC 105.210; (2) submit verification of an active

(A) pharmacist license issued under AS 08.80; or (B) retail pharmacy license issued under AS 08.80; and

(3) identify the floor space of the pharmacy in square feet. (b) An out-of-state provider seeking payment for providing pharmacy services under 7 AAC 43 or 7 AAC 105 - 7 AAC 160 must (1) be enrolled in accordance with 7 AAC 105.210; (2) be enrolled in the Medicaid program in the jurisdiction where pharmacy services are provided; (3) submit verification of an active pharmacist or retail pharmacy license in the jurisdiction where the pharmacy is located; and (4) if the pharmacy ships, mails, or delivers prescription drugs to consumers in this state more than twice a year, submit verification of a valid pharmacy registration issued under AS 08.80.158. (c) A physician, a podiatrist, a physician assistant, an advanced nurse practitioner, a tribal health program, a federally qualified health center, or a rural health clinic that is authorized to prescribe drugs, who dispenses or plans to dispense drugs, and who seeks payment under 7 AAC 43 and 7 AAC 105 - 7 AAC 160 for dispensing drugs, must be enrolled as a dispensing provider. To enroll as a dispensing provider, the physician, podiatrist, physician assistant, advanced nurse practitioner, tribal health program, federally qualified health center, or rural health clinic must (1) be enrolled in accordance with 7 AAC 105.210 and the applicable provisions of 7 AAC 43 and 7 AAC 105 - 7 AAC 160; and (2) submit a copy of the provider’s United States Drug Enforcement Administration (DEA) certification of prescriptive authority. (Eff. 2/1/2010, Register 193)


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Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 120.110. Drug coverage. (a) Except as provided in (e) of this section, the department will pay for (1) a drug that requires a prescription; (2) a compounded prescription, if at least one ingredient requires a prescription for dispensing; (3) insulin; (4) except for a recipient who is in a long-term care facility or an intermediate care facility for the mentally retarded, a drug that has been prescribed even if that drug may be sold without a prescription, as follows:

(A) laxatives and bismuth preparations; (B) clotrimazole and miconazole vaginal creams and suppositories; (C) prenatal vitamins for pregnant and nursing women; (D) nonoxynol-9 contraceptive creams, gels, foams, and sponges; (E) respiratory saline products; (F) bacitracin ointment; (G) ferrous sulfate and ferrous gluconate in nonsustained release forms; (H) tobacco cessation products for nicotine replacement therapy; (I) loratadine; (J) omeprazole; (K) calcium.

(b) The department will pay for tobacco cessation medication therapy management (1) if initially ordered by a physician, an advanced nurse practitioner, or a physician assistant; (2) if provided by a pharmacist who

(A) has attended a continuing education course in tobacco cessation; and (B) provides practical counseling in person to a recipient for at least three minutes and no more than 10 minutes; practical counseling must be in accordance with Quick Reference Guide for Clinicians: Treating Tobacco Use and Dependence, adopted by reference under 7 AAC 160.900; and (C) maintains a record of the delivered practical counseling; and

(3) no more than once per 30-day period for a recipient. (c) The department will pay for medication therapy management for vaccine administration if provided by a pharmacist to a recipient under 21 years of age. However, the department will pay for recipients 21 years of age or older under 7 AAC 110.405(b)(2). (d) The department will pay a provider for packaging prescription medications into a mediset (1) for no more than one dispensing fee per seven-day supply; (2) if, for each specific medication in the mediset, the prescribing


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provider also prescribes that the medication be packaged in a mediset; (3) for a recipient who

(A) does not reside in a long-term care facility; and (B) has one of the following conditions or needs:

(i) chronic mental illness; (ii) anti-coagulation; (iii) a seizure disorder; (iv) residence in an assisted living home; and

(4) if the pharmacy indicates on the claim that the fee is for dispensing a pharmacy unit dose. (e) The department will not pay for the following: (1) a drug used to treat infertility, obesity, or baldness; (2) a hair or wrinkle remover; (3) drugs that are prohibited from receiving federal Medicaid matching funds under 42 C.F.R. 441.25; (4) drugs, except for birth control drugs and drugs listed in (a)(4) of this section if dispensed in an unopened container, for which more than a 30-day supply is ordered per prescription; (5) drugs used for the symptomatic relief of coughs and colds; (6) oral vitamins, except

(A) prenatal; (B) fluoride preparations; (C) folic acid; (D) vitamin A; (E) vitamin K; (F) vitamin D; (G) analogs; and (H) B-complex vitamins for renal disease;

(7) a brand-name drug if a therapeutically equivalent generic drug is on the market, unless

(A) the brand name drug is included on the Alaska Medicaid Preferred Drug List, adopted by reference in 7 AAC 160.900; or (B) the prescriber writes on the prescription "brand-name medically necessary drug" or "allergic to the inert ingredients of the generic drug"; the information may be submitted electronically or telephonically; if the information is submitted telephonically, the prescriber must document it in the recipient’s record.

(f) Outpatient drugs payable under Medicaid that are not prescribed by electronic transmission in accordance with 12 AAC 52.490 or by verbal communication must be executed on tamper-resistant paper in order to be paid by the department as the primary or secondary payor. Each prescription form must contain a serial number and the prescriber’s National Provider Identifier (NPI) number under 45 C.F.R. 162.402 - 162.414. (g) The requirements in (f) of this section do not apply to a (1) refill if the original prescription was filled before April 1, 2008; (2) prescription for which retroactive Medicaid eligibility has been


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determined under 7 AAC 100.072, except for refills that are filled after the retroactive eligibility determination date; or (3) prescription prepared in an institutional pharmacy, if the prescriber writes the prescription into the medical record, the medical staff gives the order directly to the institutional pharmacy, and the patient does not handle or have the opportunity to handle the prescription; in this paragraph, "institutional pharmacy" has the meaning given in 12 AAC 52.995(a). (h) The tamper-resistant paper required under (f) of this section must include at least one industry-recognized feature designed to prevent unauthorized copying of a completed prescription, at least one industry-recognized feature designed to prevent the erasure or modification of information written on the prescription by the prescriber, and at least one industry-recognized feature designed to prevent the use of counterfeit prescription forms. For purposes of this subsection, industry-recognized features designed to prevent (1) unauthorized copying of a completed or blank prescription form include

(A) high-security watermarks on the reverse side of blank prescriptions; (B) thermochromic ink that changes color or disappears when warmed; (C) security patterns; (D) void pantographs; (E) microprinting (F) prismatic printing; (G) lenticular patterns; and (H) encodation schemes;

(2) erasure or modification of information written on the prescription by the prescriber include tamper-resistant background ink that shows erasures or attempts to change written information in accordance with any of the following techniques:

(A) toner anchorage used to complicate the removal of toner; (B) chemical stains used to reveal chemical eradication attempts against ink or toner; (C) laid lines used to reveal cut-paste attempts on an item; (D) chemical reactive inks used to reveal washing attacks; (E) overcoatings, laminates, and varnishes used to secure written content on the item; (F) erasable ink backgrounds used to reveal attempts at ink and toner removal; (G) borders and fill characters used to complicate attempts to add-on extra information; (H) on-item encodation techniques, bar codes, and patterns used to validate item content; and

(3) the use of counterfeit prescription forms include (A) serially numbered blanks; (B) duplicate or triplicate blanks; (C) thermochromic ink that changes color or disappears when


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warmed; and (D) color-shifting ink that changes color when viewed from different angles.

(i) The department will pay a provider for filling a prescription that does not comply with (f) - (h) of this section, as follows: (1) if the prescription is for a schedule II controlled substance, the prescriber must, no more than 72 hours after the date the prescription was filled, provide the pharmacy with a prescription transmitted by writing on tamper-resistant paper that complies with (f) - (h) of this section; (2) if the prescription is for a schedule III, IV, or V controlled substance, the prescriber must, no more than 72 hours after the date the prescription was filled, provide the pharmacy with a prescription transmitted by

(A) facsimile; the facsimile transmission must be in accordance with 12 AAC 52.490; (B) telephone; or (C) writing on tamper-resistant paper that complies with (f) - (h) of this section;

(3) if the prescription is for a noncontrolled substance, the prescriber must, no more than 72 hours after the date the prescription was filled, provide the pharmacy with a prescription transmitted by

(A) any form of electronic transmission in accordance with 12 AAC 52.490; (B) telephone; or (C) writing on tamper-resistant paper that complies with (f) - (h) of this section;

(4) in this subsection, "schedule," used in conjunction with a controlled substance, means the relevant schedule of controlled substances under 21 U.S.C. 812 (sec. 202, Federal Controlled Substances Act). (j) If a written prescription does not comply with (f) - (i) of this section, the monetary value of that prescription claim may be recouped by the department during pre- or postpayment review. (k) In this section, "mediset" means a quantity or unit dose of a prescription medication that the provider repackages into single-dose packing to help a recipient adhere to difficult dosing regimens. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 120.120. Drug use review. (a) The purpose of this section is to establish a drug use review program to comply with the requirements of 42 U.S.C. 1396r-8(g). The drug use review program primarily consists of prospective drug use review, retrospective drug use review, and educational outreach. The purpose of drug use review is to screen for potential drug therapy problems, identify and prevent abuse of prescribed drugs, and prevent inappropriate or unnecessary drug use. This section applies only to the prescription and dispensing of a drug provided to a Medicaid recipient who is not a recipient in a hospital or nursing facility. (b) As part of the prospective drug use review required in (a) of this section, and before the department will pay a pharmacy, a pharmacist shall make a reasonable effort


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to review a recipient’s drug therapy before a prescription is delivered to the recipient, including obtaining and maintaining the following information for each Medicaid recipient: (1) name; (2) address; (3) telephone number; (4) date of birth or age; (5) gender; (6) medical history, including any current illness, that the pharmacist considers significant; (7) allergies; (8) drug reactions; (9) medications currently used; (10) medical devices currently used; (11) the pharmacist’s comments relating to the recipient’s drug therapy. (c) As part of the prospective drug use review under this section, a pharmacist shall review the prescription, either manually or by computer, against the following criteria: (1) therapeutic duplication; (2) drug-disease contraindications; (3) interactions between the prescription and other drugs being taken; (4) incorrect dose or duration; (5) possible allergic reactions; (6) potential for clinical abuse or misuse. (d) To complete the prospective drug use review under this section, a pharmacist shall provide the recipient with recipient counseling, as required by 12 AAC 52.585, and shall document in a permanent record the recipient’s acceptance or refusal of counseling. (e) In accordance with 42 C.F.R. 456.716, the department establishes a drug use review committee to help the department comply with federal drug use review requirements. The drug use review committee will help the department (1) implement prospective drug use review in accordance with 42 C.F.R. 456.705, including recommending changes to the pharmacist review practices described in this section; (2) implement retrospective drug use review in accordance with 42 C.F.R. 42 C.F.R. 456.709, including periodic examination of past drug prescription practices; (3) assess drug use data in accordance with 42 C.F.R. 456.703; (4) implement an educational program in accordance with 42 C.F.R. 456.711, including recommending changes in prescribing or dispensing practices when appropriate to meet the intent of this section; and (5) prepare and submit an annual report to the United States Department of Health and Human Services in accordance with 42 C.F.R. 456.712. (f) Members of the drug use review committee will be nominated by the department and appointed by the commissioner to a three-year term, except that the term length of initial appointments to the committee may be varied by the commissioner to effect staggered expiration dates. A member may not serve more than two consecutive terms. If an individual has not served for three consecutive years, that individual may be


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reappointed to the committee, not to exceed two consecutive terms. The drug use review committee shall consist of at least (1) one-third, but no more than 51 percent, licensed and actively practicing physicians; (2) one-third licensed and actively practicing pharmacists; (3) an employee of the department; and (4) at the discretion of the commissioner, other health care providers. (g) For purposes of this section, "pharmacist" includes a person who dispenses prescription drugs for outpatient use. (h) For purposes of this section, 42 C.F.R. 456.703, 456.705, 456.711, 456.712, and 456.716 are adopted by reference in 7 AAC 160.900. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 120.130. Prior authorization and limitations on prescribed drugs. (a) Except as provided in (b) of this section, a prescribing or dispensing provider must obtain prior authorization from the department for a medically accepted indication before dispensing drugs on the Alaska Medicaid Prior-authorized Medications List, adopted by reference in 7 AAC 160.900. (b) In an emergency, the department will pay for no more than a five-day supply of a drug on the Alaska Medicaid Prior-authorized Medications List that is dispensed before the department has given prior authorization under (a) of this section. After the drug has been dispensed, the prescribing provider must obtain prior authorization from the department. If the department authorizes payment for the dispensing of the drug, the department will include payment for the drug dispensed before the provider received prior authorization under (a) of this section. If the department does not authorize payment, the department will not pay for the drugs dispensed before the provider requested prior authorization. (c) As necessary to prevent waste or to address fraud and abuse, the department may limit its payment to minimum or maximum quantities allowed of a specific prescribed drug or a therapeutic drug class, or limit the number of refills of a specific prescribed drug or a therapeutic drug class. (d) The department may require prior authorization for a recipient based upon the recipient’s previous use of drugs. (e) In this section, "medically accepted indication" has the meaning given in 42 U.S.C. 1396r-8(k)(6), adopted by reference in 7 AAC 160.900. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 120.140. Preferred drug list. (a) The department will pay for preferred drugs on the Alaska Medicaid Preferred Drug List, adopted by reference in 7 AAC 160.900 and established by the department under this section. (b) The department will pay for drugs that are identified as nonpreferred on the Alaska Medicaid Preferred Drug List, adopted by reference in 7 AAC 160.900, if (1) the prescriber writes the prescription in accordance with 7 AAC 120.110(e)(7); (2) the pharmacy or dispensing provider is a tribal health program


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pharmacy or dispensing provider with access to a federal supply of prescription drugs; (3) the physician or pharmacy obtains a prior authorization for drugs included in the Alaska Medicaid Prior-authorized Medications List, adopted by reference in 7 AAC 160.900; or (4) the department gives prior authorization under 7 AAC 120.130(d). (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040

Article 2. Durable Medical Equipment and Medical Supplies; Related Services. Section 200. Enrollment; general provisions; covered items and services 205. Noncovered items and services 210. Prior authorization 215. Purchase of items 220. Replacement of items 225. Rental of items; general provisions 230. Rental of items; changes during rental periods 235. Respiratory therapy equipment, supplies, and assessment visits 240. Enteral and oral nutritional products 245. Home infusion therapy 299. Definitions 7 AAC 120.200. Enrollment; general provisions; covered items and services. (a) The department may enroll under this section a provider that provides the department with evidence that the provider holds a valid business license issued under AS 43.70 and 12 AAC 12. The department will enroll a provider under this section as either a (1) durable medical equipment provider, if the provider provides

(A) durable medical equipment; (B) medical supplies; (C) respiratory therapy assessment visits; (D) home infusion therapy services; or (E) noncustomized-fabricated orthotics; or

(2) prosthetics and orthotics provider, regardless of whether the provider provides other items or services in (1) of this subsection, if the provider

(A) provides prosthetics and orthotics; and (B) is certified by the American Board of Certification in Prosthetics and Orthotics, the Board for Orthotist/Prosthetist Certification, the National Examining Board of Ocularists, Inc., or other similar certifying agencies approved by the department.

(b) Subject to the applicable provisions of 7 AAC 120.200 - 7 AAC 120.299, the department will pay a provider for medically necessary durable medical equipment, medical supplies, prosthetics, orthotics, or noncustomized-fabricated orthotics furnished to a recipient, if (1) the item

(A) is prescribed by the attending physician, physician assistant, advanced nurse practitioner, physical therapist, occupational therapist, or speech-


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language pathologist, acting within the scope of that person’s license; (B) is appropriate for use in the recipient’s home, school, or community; and (C) is not provided by, or under arrangements made by, a home health agency;

(2) the provider furnishes orientation and training to the recipient regarding the proper use of the item, and includes proof of compliance with this paragraph in its records; the provider shall submit this proof to the department upon request; and (3) prior authorization, if required under 7 AAC 120.210, is obtained from the department. (c) Subject to the applicable provisions of 7 AAC 120.200 - 7 AAC 120.299, the department will pay a provider enrolled under this section for continuous oxygen used by a recipient in a skilled nursing facility or intermediate care facility if the skilled nursing facility or intermediate care facility has not been authorized to provide continuous oxygen under 7 AAC 140.580. (d) Subject to the applicable provisions of 7 AAC 120.200 - 7 AAC 120.299, the department will pay a provider enrolled under this section for the purchase or rental of durable medical equipment for a recipient in a skilled nursing facility or intermediate care facility if the purchase or rental is medically necessary for the recipient’s preparation for discharge or for the actual discharge to home. A rental or purchase may not be arranged sooner than 30 days before the scheduled discharge and will be given prior authorization only if the equipment is not provided by the skilled nursing facility or intermediate care facility. The department may pay for trial use of rental equipment necessary for preparing a recipient for discharge. (e) Subject to the applicable provisions of 7 AAC 120.200 - 7 AAC 120.299, the department will pay a provider enrolled under this section for home infusion therapy services if the services are (1) ordered by

(A) the attending physician as part of a written home health plan of care under 7 AAC 125.320; or (B) a physician as part of a written hospice plan of care under 7 AAC 140.275;

(2) reviewed at least every 60 days by the attending physician to determine the ongoing medical need for the service; and (3) is appropriate for use in the recipient’s home, school, or community. (f) The department will pay a home infusion therapy provider for one skilled nursing visit for catheter insertion and patient instruction at a hospital on the day of discharge. (g) Subject to applicable provisions of 7 AAC 120.200 - 7 AAC 120.299, the department will pay a provider enrolled under this section for medically necessary medical supplies or respiratory therapy assessment visits furnished to a recipient who is receiving hospice care services, if the supplies or assessment visits are (1) ordered by a physician as part of a written hospice plan of care under 7 AAC 140.275 and the physician reviews the recipient’s continuing medical need for the items; and


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(2) appropriate for use in the recipient’s home, school, or community. (h) Subject to the applicable provisions of 7 AAC 120.200 - 7 AAC 120.299, the department will pay a provider enrolled under this section for the following items if described by a national drug code (NDC): (1) skin sealant; (2) skin protectant; (3) skin moisturizer; (4) skin ointment; (5) skin cleanser; (6) skin sanitizer. (i) The department will pay a provider enrolled under this section for the reasonable and necessary costs of delivery and dispensing expenses incurred in the delivery of the items from the dispensing provider to the recipient if the recipient resides outside the municipality where the business of the enrolled servicing provider is located and the item is unavailable in the municipality in which the recipient resides. If the charge is over $50, the provider must submit (1) an electronic claim, supported by

(A) the recipient’s name; (B) the recipient’s address; (C) information, such as a serial number, that identifies the item; (D) the delivery date; and (E) the total charges; or

(2) a paper claim, including an invoice that shows (A) the recipient’s name; (B) the recipient’s address; (C) information, such as a serial number, that identifies the item; (D) the delivery date; and (E) the total charges.

(j) The department will not pay separately for the costs of administrative expenses. The following costs are considered administrative expenses and are included in the payment for the durable medical equipment, medical supplies, prosthetics, orthotics, and noncustomized-fabricated orthotics: (1) telephone responses to questions; (2) mileage; (3) travel expenses; (4) travel time; (5) setting up an item; (6) installation; (7) orientation and training regarding the proper use of the item. (k) A prescribing provider under (b)(1)(A) of this section shall review the continued medical necessity for the durable medical equipment, supplies, prosthetics, or orthotics annually. The department may require more frequent or less frequent reviews based on the nature of the item prescribed. (l) A provider of durable medical equipment, medical supplies, prosthetics, orthotics, or noncustomized-fabricated orthotics shall (1) document a recipient’s request for a 30-day refill;


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(2) accept returns from recipients of any substandard item; for purposes of this paragraph, "substandard item" means an item that does not function in a manner that meets the prescribed need or specifications; and (3) upon request, provide proof, in the form of copies of letters, logs, or signed notices, that it has provided Medicaid recipients with warranty information for Medicaid-covered items. (m) The department will only pay for required medical supplies for up to a 30-day supply. The department may seek recovery under 7 AAC 105.260 of payment for services or items determined to be medically unnecessary and impose sanctions under 7 AAC 105.400 - 7 AAC 105.490. (n) The department may enter into a contract under AS 36.30, a grant, or other arrangement permitted by law, with a provider authorizing that provider to (1) provide durable medical equipment, medical supplies, prosthetics, orthotics, or noncustomized-fabricated orthotics; or (2) serve a specific geographic region and provide incontinence supplies, including

(A) garments; (B) liners; (C) underpads; (D) nonsterile gloves; (E) diaper wipes; and (F) disposable washcloths.

(o) In addition to the requirements of (a) of this section, a provider enrolled with the department under this section shall provide to the department evidence that the provider is enrolled as a Medicare provider for durable medical equipment, prosthetics, orthotics, and supplies. (p) Subject to prior authorization as required under 7 AAC 120.210, the department will pay for (1) disposable incontinence products including diapers, liners, underpads, wipes, and washcloths for recipients three years of age or older if

(A) the items are prescribed by the recipient’s attending physician, physician’s assistant, or advanced nurse practitioner on an incontinence prescription certificate of medical necessity; (B) the items are medically necessary for a medical condition resulting in bladder or bowel incontinence; and (C) the recipient has not responded to, would not benefit from, or has failed bowel or bladder training;

(2) reusable protective underpads, skin sealants, skin protectants, skin cleansers, skin sanitizers, and skin ointments if

(A) the items are prescribed by the recipient’s attending physician, physician’s assistant, or advanced nurse practitioner on an incontinence prescription certificate of medical necessity; and (B) the items are medically necessary for a medical condition resulting in bladder or bowel incontinence.

(q) In addition to meeting the requirements in 7 AAC 105.230, a recipient’s


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medical record must contain documentation to substantiate the answers on an incontinence prescription certificate of medical necessity or a certificate of medical necessity if required under 7 AAC 120.210. A copy of the signed incontinence prescription certificate of medical necessity or the certificate of medical necessity must be maintained in the recipient’s medical record. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 AS 47.05.015 Editor’s note: The United States Food and Drug Administration, Center for Drug Evaluation and Research’s national drug code compilation referred to in 7 AAC 120.200(g) is available at the following Internet address: www.fda.gov/cder/ndc/index.htm. Information on how to enroll with Medicare may be obtained from United States Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) at the following Internet address: http://www.cms.hhs.gov/cmsforms/downloads/cms855s.pdf. 7 AAC 120.205. Noncovered items and services. (a) Except as provided otherwise in this section, the department will not pay separately for durable medical equipment while the recipient is (1) in a hospital, a skilled nursing facility, or an intermediate care facility; or (2) receiving hospice care services. (b) The department will not pay separately for home infusion therapy services (1) while the recipient is in a hospital, a skilled nursing facility, or an intermediate care facility; (2) if like services are provided by or under arrangements made by a home health agency; (3) if, on the same day, like services are provided by a hospital or facility during an outpatient visit; or (4) while the recipient is receiving hospice care services and the services are

(A) related to the treatment of the terminal illness that qualifies the recipient for hospice care; or (B) provided by or under the arrangements made by the hospice program.

(c) The department will not pay for medical supplies or respiratory therapy assessment visits furnished to a recipient who is receiving hospice care services if the supplies or assessment visits are (1) related to the treatment of the terminal illness that qualifies the recipient for hospice care; or (2) provided by or under arrangements made by the hospice program. (d) The department will not pay for specialized medical equipment, as defined in 7 AAC 130.305, under 7 AAC 120.200 - 7 AAC 120.299. (e) The department will not pay for the repair of durable medical equipment while the recipient is in a skilled nursing facility or an intermediate care facility. (f) The department will not pay separately for the repair, return shipping, or preventive maintenance or service of durable medical equipment, prosthetics, or orthotics for which the cost of repair, return shipping, or preventive maintenance or service is


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included in the rental fee. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 120.210. Prior authorization. (a) A provider seeking prior authorization must make a request electronically or in writing on a certificate of medical necessity. (b) Prior authorization is required for (1) the rental of durable medical equipment; (2) medical supplies that exceed a 30-day limit set by the department; the department will set the 30-day limit based on the 75th percentile of recipient use in calendar year 2004, and will review the limit at least biennially thereafter; (3) requests that exceed the maximum allowable payment for durable medical equipment, medical supplies, noncustomized-fabricated orthotics, prosthetics, or orthotics under 7 AAC 145.420; (4) customized durable medical equipment; (5) the following incontinence supplies:

(A) garments; (B) liners; (C) underpads; (D) nonsterile gloves; (E) diaper wipes; (F) disposable washcloths;

(6) the following items: (A) skin sealant; (B) skin protectant; (C) skin moisturizer; (D) skin ointment; (E) skin cleansers; (F) skin sanitizers;

(7) items that are listed on the department’s Durable Medical Equipment Prior Authorization List, adopted by reference in 7 AAC 160.900; (8) items that are identified as miscellaneous in the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services’s (CMS) Healthcare Common Procedure Coding System (HCPCS), adopted by reference in 7 AAC 160.900; (9) respiratory therapy assessment visits for ventilator-dependent recipients; (10) home infusion therapy; (11) enteral and oral nutritional products; (12) the purchase of durable medical equipment for a recipient in a skilled nursing facility or intermediate care facility; (13) continuous oxygen for a recipient in a skilled nursing facility or an intermediate care facility; and (14) the purchase of durable medical equipment if the charge to the department is over $1,000. (c) A request for prior authorization must include


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(1) a certificate of medical necessity completed by the attending (A) physician; (B) physician assistant; (C) advanced nurse practitioner; (D) physical therapist; (E) occupational therapist; or (F) speech-language pathologist;

(2) a written statement by the person under (1) of this subsection that the recipient’s condition requires the more costly durable medical equipment, medical supply, noncustomized-fabricated orthotics, prosthetics, or orthotics if the request is for payment that exceeds the maximum allowable payment under 7 AAC 145.420; (3) documentation by the person under (1) of this subsection that the item or service is necessary to treat, correct, or ameliorate a defect, condition, or physical or mental illness if the recipient is under 21 years of age; and (4) for a request for incontinence supplies, an incontinence prescription form,

(A) for a request for incontinence supplies completed by the recipient’s attending physician, physician’s assistant, or advanced nurse practitioner, on a form provided by the department, that includes the

(i) diagnosis that is related to the cause or is causing the incontinence of the bladder, bowels, or both; (ii) diagnosis of the type of incontinence; (iii) prognosis for controlling incontinence; and (iv) item or items to be dispensed; and

(B) an incontinence certificate of medical necessity form completed by the recipient’s attending physician, physician’s assistant, advanced nurse practitioner, or the department’s designee, on a form provided by the department, that includes the

(i) frequency of incontinence; (ii) duration of need; (iii) diuretic or other medications that increase output; (iv) products currently being used; (v) skin integrity or vulnerability to skin breakdown; (vi) measurements for product sizes; (vii) quantity of item or items; (viii) known allergies to product materials; (ix) description of activities outside of the home; and (x) description of abilities to manage incontinence independently or with assistance.

(d) In addition to the requirements of (c) of this section, a prior authorization request for the following durable medical equipment or medical supplies must include, if available for the item, manufacturer information, the item description or number, the global trade item number (GTIN), the suggested list price, the serial number, and the national drug code (NDC): (1) items that are identified as miscellaneous in the Healthcare Common Procedure Coding System (HCPCS), adopted by reference in 7 AAC 160.900;


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(2) customized durable medical equipment; (3) requests that exceed the maximum allowable payment under 7 AAC 145.420 for the item; (4) the following items:

(A) skin sealant; (B) skin protectant; (C) skin moisturizer; (D) skin ointment; (E) skin cleanser; (F) skin sanitizer.

(e) Based on its review under this section, the department will give prior authorization if (1) documentation under (c) and (d) of this section has been provided, as applicable; (2) payment is appropriate under 7 AAC 105 - 7 AAC 160; and (3) the information reviewed otherwise supports approval of the request. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 Editor’s note: The certificate of medical necessity form referred to in 7 AAC 120.210(a) and (c) may be obtained from the Department of Health and Social Services, Division of Health Care Services, 4501 Business Park Boulevard, Suite 24, Anchorage, Alaska 99503-7167. The United States Food and Drug Administration, Center for Drug Evaluation and Research’s national drug code compilation referred to in 7 AAC 120.210(d) is available at the following Internet address: www.fda.gov/cder/ndc/index.htm. The incontinence prescription form and the incontinence certificate of medical necessity form referred to in 7 AAC 120.210(c)(4) may be obtained from the Department of Health and Social Services, Division of Health Care Services, 4501 Business Park Boulevard, Suite 24, Anchorage, Alaska 99503. 7 AAC 120.215. Purchase of items. (a) The department may authorize the purchase of new durable medical equipment, medical supplies, prosthetics, orthotics, and noncustomized-fabricated orthotics. The item becomes the property of the recipient for whom it is purchased. The enrolled provider shall (1) transfer ownership of the item, including any warranty, to the recipient; and (2) assure that the item was not previously used. (b) The department will not authorize the purchase of an item that requires continuous rental under 7 AAC 120.225(a)(3). (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 120.220. Replacement of items. (a) Subject to applicable requirements of 7 AAC 120.200 - 7 AAC 120.299, the department will pay for the purchase or rental of replacement durable medical equipment, prosthetics, orthotics, and noncustomized-fabricated orthotics if the (1) replacement is necessary to replace an item that has been in continuous use by the recipient for the item’s reasonable useful lifetime and the department determines that the item is lost or irreparably damaged; (2) item is not covered by a manufacturer’s warranty; and


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(3) provider replaces the item with a like item, and if the original item was rented, continues renting the replacement in accordance with 7 AAC 120.225. (b) A replacement that is needed because of item wear or a change in the recipient’s condition must be supported by current documentation of medical necessity. (c) If an item is not irreparably damaged, the department may authorize the replacement of the item if the department determines that the cost of replacement would be more cost-effective than repair. (d) For purposes of this section, useful lifetime is based on when the item is delivered to the recipient, not the age of the item, but in no case less than any useful lifetime of the item established by the manufacturer. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 120.225. Rental of items; general provisions. (a) Prior authorization for the following rentals of durable medical equipment is required: (1) rental for anticipated short-term use; (2) capped rental, if

(A) a short-term rental becomes long-term and the total rental period is 12 months; or (B) an item requires rental but the department limits payment to no more than 12 months;

(3) continuous rental of an item that requires frequent servicing and maintenance, including an apnea monitor and oxygen equipment, and of a breast pump. (b) Regardless of the type of rental under (a) of this section, (1) the department will only pay the remaining portion of the full purchase price, not rental plus the full purchase price; the provisions of this paragraph do not apply to an item that is continuously rented under (a)(3) of this section; (2) the department will review the length of need for the item and its cost before authorizing payment for rental or purchase; (3) the cost of any necessary repair, return shipping, or maintenance is included in the rental fee; and (4) when total rental payments reach the purchase price, except for an item that is continuously rented under (a)(3) of this section, repair is covered after 60 days or when the warranty expires, whichever is later. (c) Subject to applicable requirements of 7 AAC 120.200 - 7 AAC 120.299, the department will pay for the capped rental of an item if the provider (1) transfers ownership of the item, including any warranty, to the recipient for whom it was rented; and (2) replaces the item with a new item if it was previously used by a person other than the recipient before it was rented to the recipient. (d) The department will pay a provider by rental period. The department will not pay a provider for any item that exceeds 12 months of continuous use, except for an item described in (a)(3) of this section. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 120.230. Rental of items; changes during rental periods. (a) Except as otherwise provided in this section, an interruption in a rental period affects the


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department’s payment as follows: (1) a rental period is not affected by an interruption of less than 30 days; if an interruption continues beyond the end of the rental month in which use ceases, the department will pay for the rental month in which use ceased, but will not make an additional payment until use resumes; a new date of service will be established when use resumes; (2) rental units for which prior authorization has been received, but for which no payment is made, do not apply toward a capped rental period; (3) if an interruption is or exceeds 30 consecutive days, or if the original rental period expires during the interruption, the provider shall submit to the department a new prior authorization request under 7 AAC 120.210, with a statement that explains the reason for the interruption; if the department approves the request, a new rental period begins. (b) A recipient’s change of address does not affect the rental period for that recipient. (c) Except as otherwise provided in this section, if an item is modified or replaced with a different item, the rental will continue to be applied against the current rental period and payment will be based on the least expensive item that is medically suited to the rental purpose. If the rental period has expired, additional payment will not be made for a modified or replaced item unless the provider submits to the department, on a form provided by the department, certification of medical necessity for the modified or replaced item from a physician, a physician assistant, an advanced nurse practitioner, a physical therapist, an occupational therapist, or a speech-language pathologist. If the department approves the request, a new rental period begins. (d) If an addition is made to an existing item because of a substantial change in the recipient’s medical need, the rental period for the original item continues and a new rental period begins for the added item. (e) If the recipient changes providers during the rental period, a new rental period does not begin. The new provider shall continue to supply the item during the remaining rental period. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 Editor’s note: The certification of medical necessity form referred to in 7 AAC 120.230(c) may be obtained from the Department of Health and Social Services, Division of Health Care Services, 4501 Business Park Boulevard, Suite 24, Anchorage, Alaska 99503-7167. 7 AAC 120.235. Respiratory therapy equipment, supplies, and assessment visits. (a) The department will pay a provider enrolled under 7 AAC 120.200 for respiratory therapy equipment and supplies if the (1) provider employs or contracts with a

(A) registered respiratory therapist who (i) holds a valid national registry number and certificate from the National Board for Respiratory Care (NBRC) or a certificate from another body that the National Board for Respiratory Care recognizes as a credentialing equivalent; and (ii) is enrolled as a rendering provider under 7 AAC 105.210; or


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(B) certified respiratory therapy technician who (i) holds a valid national certificate from the National Board for Respiratory Care (NBRC) or a certificate from another body that the National Board for Respiratory Care recognizes as a credentialing equivalent; and (ii) is enrolled as a rendering provider under 7 AAC 105.210; and

(2) equipment is not provided by, or under arrangements made by, a home health agency or hospice program. (b) The department will not pay a registered respiratory therapist or enrolled certified respiratory therapy technician separately for respiratory therapy assessment visits. The department will pay a durable medical equipment provider at the rate identified in 7 AAC 145.420 for each assessment provided to a ventilator-dependent recipient by a registered respiratory therapist or a certified respiratory therapy technician during an assessment visit, if the visit is (1) given prior authorization as part of the recipient’s plan of care; and (2) certified as medically necessary by the recipient’s attending physician, physician assistant, or advanced nurse practitioner, on a form provided by the department. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 Editor’s note: The certification of medical necessity form referred to in 7 AAC 120.235(b) may be obtained from the Department of Health and Social Services, Division of Health Care Services, 4501 Business Park Boulevard, Suite 24, Anchorage, Alaska 99503-7167. 7 AAC 120.240. Enteral and oral nutritional products. (a) Subject to applicable requirements of 7 AAC 120.200 - 7 AAC 120.299, the department will pay a provider enrolled under 7 AAC 120.200 for enteral and oral nutritional products at the rate established in 7 AAC 145.420 if the products are (1) not provided by, or under arrangements made by, a home health agency or hospice program; (2) prescribed by the attending physician, physician assistant, or advanced nurse practitioner; (3) certified as medically necessary by the attending physician, physician assistant, advanced nurse practitioner, or dietitian on a form provided by the department; certification of medical necessity must indicate that sufficient caloric or protein intake is not obtainable through regular, liquefied, or pureed food; and (4) identified as an enteral formula in the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services’s (CMS) Healthcare Common Procedure Coding System (HCPCS), adopted by reference in 7 AAC 160.900. (b) In this section, "dietitian" means an individual who is licensed under AS 08.38 as a dietitian. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 Editor’s note: The certification of medical necessity form referred to in 7 AAC 120.240 may be obtained from the Department of Health and Social Services, Division of Health Care Services, 4501


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Business Park Boulevard, Suite 24, Anchorage, Alaska 99503-7167. 7 AAC 120.245. Home infusion therapy. (a) The department will enroll a provider of home infusion therapy services if the provider (1) meets the requirements of this section and 7 AAC 120.200(a); (2) presents evidence of a pharmacy or pharmacist license issued under AS 08.80; and (3) documents that it meets the guidelines for pharmacies and pharmacists under 12 AAC 52.400 - 12 AAC 52.440, on a form provided by the department. (b) The department will pay a provider that employs or contracts with a registered nurse who performs home infusion nursing services and has provided to the provider documentation of training and skills in (1) intravenous insertion techniques; (2) parenteral administration; (3) line and site management; and (4) the proper use of equipment. (c) For drugs covered under 7 AAC 120.110 and used in home infusion therapy, the department will accept electronic claims in the standard claim format adopted under 45 C.F.R. 162.1102(b)(1) by the United States Secretary of Health and Human Services. (d) The department will not separately pay a provider under this section for the following items identified in the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services’s (CMS) Healthcare Common Procedure Coding System (HCPCS), adopted by reference in 7 AAC 160.900: (1) routine servicing of an infusion device for equipment already included under 7 AAC 145.420(j)(2); (2) catheter care and maintenance identified as "not otherwise classified"; (3) nursing services only for insertion of a peripherally inserted central venous catheter (PICC); (4) nursing services only for insertion of a midline central venous catheter; (5) nursing services when same-day services are provided by a home health agency; (6) nursing services when same-day services are provided at a hospital or facility during an outpatient visit; (7) the following items, without a specific dosage timing or quantity:

(A) pain management infusion; (B) chemotherapy infusion; (C) total parenteral nutrition (TPN); (D) hydration therapy; (E) antibiotic, antiviral, or antifungal therapy; (F) professional pharmacy services;

(8) continuous insulin infusion therapy; (9) after-hours care; (10) home injectable therapy; (11) dietitian services;


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(12) delivery or service to high-risk areas requiring escort or extra protection; (13) high-technology registered nursing services; (14) infusion suite services; (15) home therapy enteral nutrition; (16) home administration of aerosol drug therapy; (17) home transfusion of blood products; (18) home irrigation therapy. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 Editor’s note: A copy of the pharmacists’ guidelines form referred to in 7 AAC 120.245(a) may be obtained from the Department of Health and Social Services, Division of Health Care Services, 4501 Business Park Boulevard, Suite 24, Anchorage, Alaska 99503-7167. A copy of the standard claim format referred to in 7 AAC 120.245(c) may be obtained from the National Council for Prescription Drug Programs, 9240 E. Raintree Dr., Scottsdale, Arizona 85260-7518; telephone: (480) 477-1000; Internet address: http://www.ncpdp.org. 7 AAC 120.299. Definitions. In 7 AAC 120.200 - 7 AAC 120.299, (1) "capped rental" means the rental of durable medical equipment, prosthetics, or orthotics for no more than 12 months; (2) "customized durable medical equipment" means durable medical equipment that is uniquely constructed or substantially modified for a specific recipient in accordance with the description and orders of a physician, a physician assistant, or an advanced nurse practitioner, and that is so different from another item used for the same purpose that the two items cannot be grouped together for pricing purposes; (3) "durable medical equipment" means equipment that

(A) can withstand repeated use; (B) is primarily and customarily used to serve a medical purpose; (C) generally is not useful to an individual in the absence of an illness or injury; and (D) is appropriate for use in the home, school, or community;

(4) "medical supplies" means supplies that (A) do not withstand repeated use; (B) are primarily and customarily used to serve a medical purpose; (C) generally are not useful to an individual in the absence of an illness or injury; and (D) are appropriate for use in the home, school, or community;

(5) "miscellaneous" means an item or service listed in the Healthcare Common Procedure Coding System (HCPCS), adopted by reference in 7 AAC 160.900, that is

(A) described as "miscellaneous," "not otherwise classified," or "not otherwise specified"; or (B) without a specific description or identifier;

(6) "national drug code" means the code assigned by the United States Food and Drug Administration under 21 C.F.R. Part 207 (registration of producers of drugs and listing of drugs in commercial distribution); (7) "rental period" means the number of rental units authorized by the


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department; (8) "rental unit" means one day for anticipated short-term rental, and one 30-day period for anticipated long-term or continuous use. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040

Article 3. Transportation and Accommodation Services. Section 400. Transportation provider enrollment 405. Transportation and accommodation covered services 410. Prior authorization for nonemergency transportation services 415. Emergency transportation services 420. Air ambulance services 425. Accommodation services 430. Authorized escort 435. Prematernal home services 440. Mortuary expenditure 445. Contracted transportation and accommodation services 490. Definitions 7 AAC 120.400. Transportation provider enrollment. To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing transportation and accommodation services, the provider must (1) enroll with the department as a provider of transportation or accommodation services in accordance with 7 AAC 105.210; (2) if providing transportation or accommodation services out of state, be enrolled as a Medicaid provider of transportation or accommodation services in the jurisdiction services are provided; and (3) hold all certificates and licenses required by law to perform the services. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 120.405. Transportation and accommodation covered services. (a) The department will pay a provider for only those transportation and accommodation services that are (1) provided to assist the recipient in receiving medically necessary services; and (2) authorized by the department under 7 AAC 120.410 and 7 AAC 120.415. (b) The department may approve transportation and accommodations outside the recipient’s community of residence to obtain medically necessary services for the recipient if (1) those services are not available in the recipient’s community; (2) the total cost for Medicaid services with transportation and accommodation costs included is less than the cost of the services at a facility within the recipient’s community of residence; or (3) the recipient is an American Indian or Alaska Native who has


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requested services from a tribal health program outside the recipient’s community of residence. (c) The department will not pay for (1) transportation or accommodations that the department determines to be excessive or inappropriate for the distance traveled or inconsistent with the medical needs of the recipient; (2) transportation for a recipient two years of age or younger if the department pays the cost for an escort to accompany the child, unless the condition of the child prevents the child from riding in the same seat as the escort; (3) transportation for a recipient who is an inpatient in a general acute care hospital and who is being transported to another location to receive medical services if the recipient remains a recipient in the general acute care hospital while absent and is to be returned to the general acute care hospital; (4) transportation for a recipient or an authorized escort to travel to a health care provider or Medicaid service provider that is not enrolled as a Medicaid provider by the department at the time the travel occurs, unless the provider is a military or veterans' facility; (5) transportation and accommodations on weekends if

(A) travel on a weekday would shorten the length of the trip; (B) the department did not give prior authorization for the weekend travel; or (C) the weekend travel is not medically necessary;

(6) ground transportation, including travel by automobile, taxi, and bus, for a recipient to travel to a health care provider within the recipient’s community of residence, unless

(A) the recipient’s medical condition justifies the need for the transportation; (B) an undue hardship would result from a denial of the transportation; or (C) the transportation is required as an EPSDT service; or

(7) separate accommodations for a recipient and escort, unless the department determines that the circumstances warrant separate accommodations. (d) The department will pay for nonemergency ground ambulance services if it is warranted by the recipient’s medical condition. Nonemergency ground ambulance services are paid at an all-inclusive rate established by the department. The department will not make an additional payment for oxygen or other basic support items associated with the travel by nonemergency ground ambulance services. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 120.410. Prior authorization for nonemergency transportation services. (a) Except as provided in (d) of this section, and except for transportation services subject to prior authorization under 7 AAC 110.205(c) and (d), transportation and accommodation services that are not required by a medical emergency must receive prior authorization from the department before the time that the service is provided. (b) The recipient’s health care provider shall request prior authorization for


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medically necessary transportation and accommodations on behalf the recipient by submitting the request to the department. The health care provider must request authorization for accommodation services at the same time it requests authorization for transportation services. (c) When reviewing a request for prior authorization, the department will consider the (1) least expensive means of transportation and accommodation for a recipient and an authorized escort; (2) recipient’s medical condition; (3) distance to the place of treatment; and (4) availability of transportation providers. (d) The department will pay for nonemergency transportation and accommodation services provided without prior authorization if (1) a recipient is forced to change authorized travel plans for reasons beyond the recipient’s control, including the cancellation of an airline flight due to weather conditions or the closing of an airport for security reasons; or (2) the medical service for which the recipient traveled reveals the need for additional services, screening, or treatment that requires the recipient to stay longer than previously approved. (e) The department will not pay the costs allowed in (d) of this section unless the recipient’s health care provider notifies the department of the change in the recipient’s travel plans no later than the next business day following the change in those plans. (f) The department will not pay for transportation on a charter air service, unless the department gives prior authorization for the transportation. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 120.415. Emergency transportation services. (a) The department will pay for medically necessary emergency air or ground transportation to the nearest facility that provides emergency care. If the recipient is an American Indian or Alaska Native, the department will, at the request of the recipient or a family member, pay for medically necessary emergency transportation to the nearest facility operated by a tribal health program that provides emergency care even though the facility is not the nearest facility that provides emergency care. (b) A claim submitted to the department for payment of costs for emergency transportation service, including ground ambulance and air ambulance service, must be accompanied by written justification of the medical emergency, including medical documentation. A ground ambulance service’s documentation of a recipient’s medical status and medical services provided may serve as adequate written justification to support a claim for emergency transportation services by a ground ambulance service. (c) The department will not pay for (1) emergency air travel in an air ambulance, on a charter airline, or on a commercial airline unless the provider submits to the department medical justification for the service required under (b) of this section no more than two business days following the date that the recipient was transported; (2) emergency transportation services to return the recipient to a residence


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or other location. (d) If the department determines that the use of an emergency ground ambulance was not medically justified, a claim for allowable costs will be paid at the nonemergency ground ambulance rate. If the department determines that the recipient’s medical condition did not warrant any form of ambulance transportation, the claim will be denied. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 120.420. Air ambulance services. (a) The department will pay for air ambulance services only if (1) the recipient is being transferred to another community to receive a medically necessary higher level of care not available in the recipient’s community; and (2) the patient is accompanied by appropriately credentialed medical personnel. (b) If a recipient needs to travel to another community to receive a lower level of care and is unable to travel on a commercial airline, the department may authorize transportation in a air ambulance, but will only pay the provider for the lift-off fee at the point of patient pickup. (c) The department will not pay for an authorized escort under 7 AAC 120.430 to accompany a recipient on an air ambulance flight. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 120.425. Accommodation services. (a) The department will pay for accommodation services, including food and lodging, incurred by a recipient and the recipient’s authorized escort who are required to travel to receive necessary medical care and cannot reasonably return to the recipient’s home community on the same day. (b) The department will pay for accommodation services at an all-inclusive flat rate established by the department. (c) The department will not pay for nonessential services as part of accommodation services. Nonessential services include (1) alcoholic beverages; (2) pay television; (3) long distance telephone calls; (4) tips; (5) laundry; (6) dry cleaning; (7) meals or lodging for a relative or guest who is not serving as an authorized escort. (d) The department will not pay for accommodations for a recipient or an authorized escort if appropriate lodging is available to the recipient or authorized escort at no expense. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 120.430. Authorized escort. (a) The department will approve transportation and accommodation services for an authorized escort to accompany a recipient during travel authorized by the department for medical treatment if


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(1) the recipient is 17 years of age or younger; or (2) the recipient is 18 years of age or older and the department determines that the escort is medically necessary for the recipient. (b) All transportation and accommodation services for an authorized escort must be approved by the department before the time that the transportation and accommodation services are provided. The recipient’s health care provider must request authorization for an escort at the same time transportation and accommodation services are requested for the recipient. If the recipient is 18 years of age or older, the recipient’s health care provider must submit sufficient information to establish medical necessity for the escort. (c) The department will not pay for transportation services for an authorized escort if the recipient is transported by ground ambulance or air ambulance. (d) The department will not pay separately for accommodations if the authorized escort and the recipient stay in the same room, unless there is a higher rate for double occupancy. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 120.435. Prematernal home services. (a) The department may enroll a prematernal home as a Medicaid provider to provide transportation and accommodation services if the prematernal home is licensed to provide lodging, meals, and medically related transportation to (1) a pregnant woman; or (2) a woman with a child less than one year of age. (b) All nonemergency transportation and accommodation services provided to a recipient by a prematernal home must be approved by the department before the time that the service is provided. Requests for an authorized stay of over 30 days must be accompanied by written medical justification for the stay. (c) The department will pay for services provided by a prematernal home to a pregnant woman in the community where delivery of the baby is planned if a physician, an advanced nurse practitioner, or a physician assistant recommends those services. (d) The department will pay for accommodation services provided by a prematernal home to a woman with a child less than one year of age if the overnight stay is necessary to provide medical services to the recipient. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 120.440. Mortuary expenditure. Medical transportation services include transportation provided by the carrier up to the time death is known or until the deceased recipient, alive at the time of pickup, reaches the source of medical care. Thereafter, transportation expense of the deceased recipient is a mortuary expenditure that is not covered by Medicaid. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 120.445. Contracted transportation and accommodation services. The department may designate one or more enrolled providers of transportation or accommodation services to serve specific geographic regions, or an agent or organization to manage travel and accommodations services, through a contract for services under AS


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36.30, a grant, or other arrangement permitted by law. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 AS 47.05.015 7 AAC 120.490. Definitions. In 7 AAC 120.400 – 7 AAC 120.490, (1) "ambulance" means any privately or publicly owned vehicle that is regularly provided or offered to be provided for the emergency transportation of a person suffering from illness, injury, or disability and licensed by the department or local licensing body; police, fire, funeral home, and other vehicles that serve a dual purpose, one of which meets this definition, also may be considered ambulances; (2) "emergency transportation" means the transportation necessary immediately when a sudden, unexpected occurrence creates a medical emergency; (3) "escort" means a person who accompanies a recipient to or from a source of medical care; the purpose of the escort accompanying a recipient may be the result of medical necessity or may be due to the age or physical or mental capacity of the recipient; the escort may be medically trained, but medical training is not required; an escort is not compensated by the department; (4) "food and lodging" means meals and sleeping facilities for the recipient, escort, or both, while the recipient is receiving medical care at a facility away from the place where the recipient regularly resides; "food and lodging" does not include

(A) meals and sleeping facilities provided by friends or relatives of either the recipient or the escort; or (B) accommodations provided in hospitals or nursing homes;

(5) "medical transportation" means transportation for medical purposes to and from any source of medical care or between medical facilities, food and lodging incidental to such transportation for both recipients and escorts when needed, and accommodations provided by prematernal homes; (6) "prematernal home" means home-like or dormitory-style accommodations that

(A) are licensed under AS 47.32; (B) use double occupancy of bedrooms on a routine basis, a shared bathroom, and meals served family-style; (C) are intended primarily for

(i) a pregnant woman from another community who is awaiting delivery of her child; or (ii) occasional short-term care to mothers and infants; and

(D) are not intended for the general public; (7) "provider of transportation" means

(A) the owner or operator of a private automobile, municipal bus, inter-community bus, taxi, scheduled airline, ferry, wheelchair coach, train, chartered aircraft, chartered boat, or other mode of transportation commonly used to transport a person; and (B) a person who contacts with an air carrier to provide chartered or scheduled air services. (Eff. 2/1/2010, Register 193)



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Chapter 125. Medicaid Coverage; Personal Care Services and Home Health Services

Article 1. Personal Care Services (7 AAC 125.010 - 7 AAC 125.199) 2. Home Health Care Services (7 AAC 125.300 - 7 AAC 125.399)

Article 1. Personal Care Services. Section 10. Purpose and scope of personal care services 20. Personal care assessment tool (PCAT) 30. Personal care covered services 40. Personal care excluded services 50. Personal care place of service 60. Personal care provider certification and enrollment 80. Personal care provider decertification and disenrollment 90. Employment of personal care assistants; qualifications 100. Safety of recipients 110. Consumer-directed and agency-based personal care programs; safety of employees;

termination of service 120. Responsibilities of personal care assistant 130. Consumer-directed personal care program; personal care agencies 140. Consumer-directed personal care program; recipient requirements 150. Agency-based personal care program; personal care agencies 160. Agency-based personal care program; personal care assistant education and training

requirements 170. Agency-based personal care program; supervising registered nurse 180. Review and appeal rights 190. Consumer-directed and agency-based personal care programs; compliance reviews 195. Payment for personal care services 199. Definitions 7 AAC 125.010. Purpose and scope of personal care services. (a) The purpose of personal care services is to enable an individual, of any age, whose needs would otherwise result in placement in a general acute care hospital or nursing facility or loss of that individual’s employment solely related to activities of daily living (ADL) to remain at home or prevent job loss. To be eligible for personal care services under 7 AAC 125.010 - 7 AAC 125.199, an individual must need extensive assistance with at least one ADL, and limited assistance with at least one other ADL, as shown by the individual’s personal care assessment tool (PCAT). (b) Personal care services must be provided by either an agency-based or consumer-directed program and must (1) be provided to a Medicaid recipient; (2) be approved in the recipient’s service plan prepared under 7 AAC 125.020; (3) receive prior authorization from the department before service is provided;


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(4) be provided by an individual who is not an immediate family member of the recipient or a legal representative and who is a personal care assistant

(A) selected by the recipient and employed by a personal care agency enrolled in the consumer-directed program under 7 AAC 125.130; or (B) employed by a personal care agency enrolled in the agency-based program under 7 AAC 125.150; and

(5) be supported by a form that (A) is provided by the department; (B) identifies the recipient’s diagnosis; and (C) is completed by a physician, a physician assistant, or an advanced nurse practitioner, who is licensed in this state or practicing or employed in a federally or tribally owned or leased health facility in this state.

(c) The department may authorize personal care services for up to a 12-month period. Reauthorization by the department for personal care services will be done on an annual basis and based upon a PCAT. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 7 AAC 125.020. Personal care assessment tool (PCAT). (a) All personal care services must be performed in accordance with a recipient’s PCAT that is approved by the department under this section. The PCAT is prepared using the department's (1) Consumer Assessment Tool (CAT), adopted by reference in 7 AAC 160.900; and (2) PCAT Authorized Services Plan form, adopted by reference in 7 AAC 160.900, including changes made under (e) of this section. (b) The department or its designee will develop the recipient’s PCAT, which must include (1) supporting documentation

(A) on a form provided by the department; (B) that identifies the recipient’s diagnosis; and (C) that is completed by a physician, a physician assistant, or an advanced nurse practitioner, who is licensed in this state or practicing or employed in a federally or tribally owned or leased health facility in this state;

(2) an assessment of the recipient’s personal care needs, prepared in accordance with (d) of this section; (3) specific instructions regarding the type and frequency of tasks the personal care assistant is expected to perform; (4) a statement of the expected outcome of the recipient’s PCAT authorized services plan; (5) for the consumer-directed program only, identification of any legal representative of the recipient and specification of the requirements of 7 AAC 125.140 for which the legal representative will be responsible; and (6) for the agency-based program only, a backup plan that defines the agency’s responsibility to

(A) provide services if the recipient’s regularly scheduled personal care assistant is unable to provide those services; (B) develop a contingency plan to ensure the health and welfare of


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the recipient if the recipient is unable to receive personal care services from either the regularly scheduled personal care assistant or from another personal care assistant provided through the backup plan; and (C) educate the recipient about the contingency plan.

(c) For the consumer-directed program only, the agency and either the recipient or the legal representative shall develop a backup plan that (1) identifies the extent to which the agency or recipient is responsible for obtaining personal care services if the recipient’s regularly scheduled personal care assistant is unable to provide those services; and (2) includes a contingency plan that

(A) defines the agency’s and the recipient’s responsibilities to work with and educate a recipient about a plan of action to ensure the health and welfare of the recipient if the recipient’s regularly scheduled personal care assistant is unable to provide personal care services and other personal care services are not available through the backup plan; and (B) informs the recipient of the risks involved.

(d) An assessment of a recipient’s need for personal care services will be (1) recorded on the recipient’s PCAT; (2) based upon personal observation of the recipient; and (3) performed by the department staff or designee. (e) Any change in a recipient’s PCAT before the end of the 12-month authorization period (1) must be developed by the department or its designee and approved as provided in (g)(1) of this section; (2) must include medical or other relevant documentation of the recipient’s condition; (3) must be recorded in the recipient’s PCAT authorized services plan records; and (4) may be made outside the recipient’s residence and without personal observation of the recipient by the department or its designee. (f) The department will establish a renewal date for a recipient’s PCAT that coincides with the renewal of a plan of care under 7 AAC 130.230 so that services are coordinated and payments are not duplicated. A copy of a recipient’s PCAT will be made part of the recipient’s service record under 7 AAC 130.200 - 7 AAC 130.319 (home and community-based waiver services; nursing facility and ICF/MR level of care), if applicable. (g) A recipient’s PCAT developed under (a) of this section does not take effect unless approved by the department. The department will approve a recipient’s PCAT if the department determines that each service listed in the PCAT (1) is of sufficient duration, amount, and scope to prevent

(A) placement in a general acute care hospital or nursing facility; or (B) loss of employment; and

(2) is supported by documentation required under (b) of this section. (h) Payment is not available under 7 AAC 125.010 - 7 AAC 125.199 for any service provided that is not identified in a recipient’s PCAT.


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(i) The department will consider a request that an individual assessment be expedited for an individual that is at increased risk to health and safety. An expedited assessment will be reviewed only for the determination of personal care services and not home and community-based waiver services under 7 AAC 130.200 - 7 AAC 130.319. An expedited assessment request must be submitted on a form and in a format provided by the department and must be supported with medical documentation. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 7 AAC 125.030. Personal care covered services. (a) If the requirements of 7 AAC 125.010 - 7 AAC 125.199 are met, the department will pay a personal care agency, whether it is enrolled in the consumer-directed or agency-based program, for services provided to a recipient in accordance with the recipient’s PCAT for (1) assistance with the recipient’s activities of daily living (ADL), including

(A) physical assistance with basic personal hygiene and grooming, including

(i) bathing; (ii) dressing; (iii) care of the mouth, hair, and skin; and (iv) filing of toenails and both cutting and filing of fingernails, excluding nail care for recipients who are diabetic or have poor circulation;

(B) physical assistance with bladder and bowel routines, including (i) helping the recipient to and from the bathroom; (ii) assisting the recipient with a bedpan or other toileting procedures; (iii) providing general hygiene care of a colostomy, an ileostomy, or an external catheter; (iv) giving suppositories that do not contain medication; (v) providing digital stimulation; and (vi) providing routine care of an incontinent recipient;

(C) assistance with eating; (D) physical assistance with transferring the recipient in and out of a bed, chair, or wheelchair and helping the recipient walk with support of a walker, cane, gait belt, braces, or crutches; and (E) physical assistance with positioning or turning a nonambulatory recipient in a bed or chair;

(2) assistance with a recipient’s instrumental activities of daily living (IADL) essential to the recipient’s health and specifically related to an approved task for an ADL need, including

(A) light housekeeping tasks; (B) changing and laundering the recipient’s bed linens; (C) laundering the recipient’s clothing; (D) meal planning and preparation; and (E) shopping; and


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(3) additional covered services, including (A) physical assistance taking and documenting the recipient’s temperature, pulse, blood pressure, and respiration when medically necessary; (B) physical assistance with setup for diabetic testing and documentation; (C) physical assistance with

(i) care of nonsterile dressings for uninfected post-operative or chronic conditions; (ii) prescribed foot care, excluding nail care for recipients who are diabetic or have poor circulation; and (iii) the application of elastic bandages and support hose;

(D) physical assistance with the use and minor maintenance of respiratory equipment and prescribed oxygen; (E) physical assistance with putting on and removing a prosthetic device; (F) assistance with self-administered routine oral medication, eye drops, and skin ointments; that assistance may include reminding the recipient and placing a medication within the recipient’s reach; (G) physical assistance with walking and simple exercises prescribed by a physician, a physician assistant, or an advanced nurse practitioner, who is licensed in this state or practicing or employed in a federally or tribally owned or leased health facility in this state; and (H) assistance with

(i) travel to and from routine medical and dental appointments; and (ii) conferring with medical or dental staff for routine medical or dental appointments.

(b) The department will pay only a personal care agency enrolled in the agency-based program for physical assistance with range-of-motion and stretching exercises, if (1) the physical assistance is provided to a recipient in accordance with the recipient’s PCAT; and (2) the exercises are prescribed by a physician, a physician assistant, or an advanced nurse practitioner, who is licensed in this state or practicing or employed in a federally or tribally owned or leased health facility in this state. (c) The department will pay only a personal care agency enrolled in the consumer-directed program for physical assistance for services provided to a recipient in accordance with the recipient’s PCAT, including health maintenance activities, urinary system management, bowel treatments, administration of medications, tube feeding, and wound care. (d) The department will pay for IADL services that are (1) provided to a recipient 18 years of age or older; and (2) approved under 7 AAC 125.020 as part of a recipient’s PCAT authorized services plan. (e) The department will pay under this section for meal preparation essential to meeting a recipient’s health needs, if the meal preparation service is (1) not duplicated by another meal service approved under 7 AAC


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130.295 or 42 U.S.C. 3001 - 3058ee (Older Americans Act); (2) provided in the recipient’s home; and (3) provided in accordance with 42 U.S.C. 3030g. (f) The department will pay under this section for up to four hours a month of assistance with shopping in the vicinity of a recipient’s residence for prescribed drugs, medical supplies, groceries, and other household items required specifically for the health and maintenance of the recipient, including items required by the recipient but also used by other occupants of the recipient’s residence. (g) If there is a second recipient in a residence, the department may authorize a personal care assistant to perform an IADL for both recipients residing in the same residence. (h) The department will authorize limited assistance, in conjunction with another service listed in this section essential to a recipient’s health and specifically related to an approved task for an ADL listed in (a)(1) of this section, if (1) the recipient’s PCAT authorized services plan supports an ADL self-performance of two or three for the respective ADL, as scored in Section E of the CAT portion of the PCAT; and (2) the recipient has a medical history of falls with injury, documented by a physician, a physician assistant, or an advanced nurse practitioner, who is licensed in this state or practicing or employed in a federally or tribally owned or leased health facility in this state. (i) A recipient who is eligible for chore services under 7 AAC 130.245 is not eligible for IADL services. If the number of 15-minute units of IADL services for which the recipient is eligible as shown by the PCAT exceeds the maximum number of 15-minute units allowed under 7 AAC 130.245 as chore services, or if chore services are not available in the recipient’s community, the recipient may choose IADL services at a level shown by the PCAT. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 7 AAC 125.040. Personal care excluded services. (a) Except as provided in (b) of this section, personal care services reimbursable under Medicaid, in both the consumer-directed and agency-based programs, do not include the following: (1) application of dressings involving prescription medication and aseptic techniques; (2) invasive body procedures; for purposes of this paragraph, invasive body procedures include injections of medications, insertion or removal of catheters, tracheostomy care, enemas, deep suctioning, tube or other enteral feedings, medication administration, and care and maintenance of intravenous equipment; (3) chore services in the home; (4) a task that the department determines could reasonably be performed by the recipient; (5) respite care intended primarily to relieve a member of the recipient’s household, a family member, or a caregiver other than a personal care assistant from the responsibility of caring for the recipient; (6) a task that is not on the recipient’s PCAT authorized services plan that has been approved under 7 AAC 125.020;


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(7) a task that requires a sterile technique or procedure, except for sterilizing or autoclaving needed supplies and equipment that, if not for the presence of a personal care assistant, a recipient would have to perform independently; (8) care that requires a technical or professional skill that a state statute or regulation mandates must be performed by a health care professional licensed or certified by the state; (9) care of other members of the recipient’s household; (10) cleaning an area not used directly by the recipient; (11) supervision, monitoring, cueing, transportation provided under 7 AAC 120.405, babysitting, social visitation, general monitoring for equipment failure, services provided under 7 AAC 130.200 - 7 AAC 130.319 (home and community-based waiver services; nursing facility and ICF/MR level of care), home maintenance, or pet care, except for a service animal; (12) tasks that supplant or duplicate assistance offered by an individual or organization without charge or that are paid for by a third party; (13) IADL under 7 AAC 125.030 if

(A) the recipient or anyone else in the residence offers to perform or financially provide the IADL for the recipient; (B) another relative, caregiver of the recipient, community or volunteer agency, or third-party payer is capable of or responsible for the provision of the IADL services; (C) IADL services, other than shopping, are greater than one-third of the total time authorized per week for personal care services; (D) other recipients living in the same residence receive IADL services under 7 AAC 125.010 - 7 AAC 125.199 or under 7 AAC 130.200 - 7 AAC 130.319 (home and community-based waiver services; nursing facility and ICF/MR level of care); or (E) the IADL services are not specifically related to a qualifying ADL listed in 7 AAC 125.030(a)(1);

(14) tasks to provide necessary food, clothing, shelter, or medical attention for a minor recipient that are a parental responsibility and are considered neglect under AS 47.10.014 if not performed. (b) In the case of a consumer-directed personal care agency, (a)(1), (7), and (8) of this section do not apply, and notwithstanding (a)(2) of this section, insertion and removal of catheters, tube or other enteral feedings, and medication administration are reimbursable under Medicaid. (c) The department will not make separate payment for personal care assistants under 7 AAC 125.010 - 7 AAC 125.199 if the recipient receives in-home support services under 7 AAC 130.265(b)(5). (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 7 AAC 125.050. Personal care place of service. (a) Personal care services may be provided only to a recipient who is living in the recipient’s personal residence and meets the requirements of this section. (b) The following living situations are specifically excluded as a recipient’s personal residence for the purposes of Medicaid payment for personal care services:


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(1) a licensed skilled or intermediate care facility or hospital; (2) a licensed intermediate care facility for the mentally retarded; (3) a foster home licensed under AS 47.32, except for recipients in a licensed foster home who are receiving residential habilitation services under 7 AAC 130.200 - 7 AAC 130.319; (4) an assisted living home licensed under AS 47.32; (5) a residence where personal care services are already paid in a contractual agreement; (6) a general acute care hospital. (c) The department will not pay for transportation, room, or board for a personal care assistant to travel with a recipient away from the recipient’s municipality of residence. However, the department will pay for a recipient’s approved services for up to 30 days annually while the recipient is away from the recipient’s municipality of residence, unless additional time is required based on documented medical necessity or for education not available in this state, if (1) the department authorizes the travel before it begins; and (2) as specified in the recipient’s PCAT, the need cannot be met during the travel period by any means other than by being accompanied by a personal care assistant. (d) In this section, "personal residence" means the dwelling that the recipient considers to be the recipient’s established or principal home and to which, if absent, the recipient intends to return. A personal residence may be real or personal property, fixed or mobile, and located on land or water, if the living conditions are appropriate for the care of the recipient, including adequate sanitary conditions for handwashing and waste disposal. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 7 AAC 125.060. Personal care provider certification and enrollment. To be certified and enrolled by the department as a provider of personal care assistant services, a personal care agency must meet the applicable certification criteria, including provider qualifications and program standards, set out in the department’s Personal Care Assistant Agency Certification Application Packet, adopted by reference in 7 AAC 160.900, which the agency must submit to the department. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 7 AAC 125.080. Personal care provider decertification and disenrollment. (a) The department may deny enrollment or certification to, or disenroll or decertify, a personal care agency as a provider for the consumer-directed or agency-based program (1) if the agency does not meet the requirements in the department’s Personal Care Assistant Agency Certification Application Packet, adopted by reference in 7 AAC 160.900; (2) for grounds and under procedures set out in 7 AAC 105.400 - 7 AAC 105.490; (3) if the agency is no longer qualified for certification under 7 AAC 105 - 7 AAC 160; or (4) if a personal care assistant does not pass a criminal history check


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conducted under 7 AAC 10.900 - 7 AAC 10.990, and the personal care agency does not terminate association with the individual in accordance with 7 AAC 10.960, unless the department grants a variance under 7 AAC 10.935. (b) Providers that are disenrolled or decertified by the department under (a)(2) or (3) of this section may appeal that decision under 7 AAC 105.270. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.05.310 AS 47.05.340 AS 47.05.300 AS 47.05.320 AS 47.07.030 7 AAC 125.090. Employment of personal care assistants; qualifications. (a) To be employed as a personal care assistant in either the consumer-directed program or the agency-based program, a personal care assistant (1) must be at least 18 years of age; (2) must meet all requirements for the position as set out in 7 AAC 125.010 - 7 AAC 125.199; (3) must be individually enrolled with the department; (4) must pass a criminal history check requested under (c) of this section unless the department grants a variance under 7 AAC 10.935; (5) may not have been denied a health care provider license or certification for a reason related to patient services described in 7 AAC 43 and 7 AAC 105 - 7 AAC 160, or ever had a license or certification revoked; and (6) must be able independently to assist the recipient with the specific ADL under 7 AAC 125.030 and services provided to a recipient. (b) To be a personal care assistant working in the agency-based program, an individual must (1) submit three letters of reference from individuals who

(A) are not employed by the same personal care agency; (B) are not under the individual’s supervision; (C) have known the personal care assistant for at least three years; and (D) attest to the personal care assistant’s good character and ability to meet the performance requirements of a personal care assistant; and

(2) submit evidence of having met the education and training requirements of 7 AAC 125.160. (c) A personal care agency is subject to the applicable requirements of AS 47.05.300 - 47.05.390 and 7 AAC 10.900 - 7 AAC 10.990 (barrier crimes, criminal history checks, and centralized registry). The personal care agency shall submit to the department a request for a criminal history check for each personal care assistant as required under 7 AAC 10.910. The department will not pay for services provided by a personal care assistant (1) for whom a criminal history check was not requested as required under 7 AAC 10.900 - 7 AAC 10.990; or (2) who does not pass a criminal history check under 7 AAC 10.900 - 7 AAC 10.990; however, except as restricted by applicable federal law, the department will not withhold payment if it grants a provisional valid criminal history check under 7 AAC 10.920 or a variance under 7 AAC 10.935.


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(d) A personal care assistant employed by a consumer-directed agency must provide proof to the employing agency of having and maintaining a valid certificate in (1) first aid issued by the American Red Cross, American Heart Association, or other agency approved by the department; and (2) cardiopulmonary resuscitation (CPR) issued by the American Red Cross, American Heart Association, or other agency approved by the department. (e) The department may waive, for up to six months, the first aid or CPR requirements of 7 AAC 125.160(a) and the first aid or CPR requirements of (d) of this section, if a personal care assistant is unable to attend the first aid or CPR courses, or obtain the first aid or CPR certificates due to reasonable cause or excusable neglect. The personal care assistant must request a waiver in writing, to the department, and must include a statement explaining the reasonable cause or excusable neglect. If the department grants a waiver, the department may prescribe an alternative method of compliance with the requirements. (f) In this section, "reasonable cause or excusable neglect" includes (1) medical emergency; (2) weather; and (3) unavailability of classes in the community. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.05.310 AS 47.05.340 AS 47.05.017 AS 47.05.320 AS 47.07.030 AS 47.05.300 7 AAC 125.100. Safety of recipients. (a) An agency or an employee of an agency in either the consumer-directed or agency-based program who has reasonable cause to believe that a recipient of any service rendered under 7 AAC 125.010 - 7 AAC 125.199 is subject to abuse or coercion of any kind, shall report that belief to the department immediately in accordance with AS 47.17.020 and AS 47.24.010. An agency or employee is also subject to the reporting requirements of 7 AAC 10.955(c) for the centralized registry established under 7 AAC 10.955. (b) If an immediate termination of services under 7 AAC 125.110 appears likely to put a recipient at risk of harm, the agency shall (1) include a statement to that effect in its notice to the department for referral of the recipient to adult protective services or the office of children’s services within the department; and (2) promptly call the department’s adult protective services hotline or the child abuse hotline. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.05.330 AS 47.07.030 Editor’s note: The hotline number for the department’s adult protective services is (800) 478-9996. The child abuse hotline number for the department is (800) 478-4444. 7 AAC 125.110. Consumer-directed and agency-based personal care programs; safety of employees; termination of service. If it appears to a consumer-directed agency or to an agency-based agency that a recipient is putting an employee of that agency at risk of harm, including financial harm, in providing personal care service,


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the agency may immediately terminate service to that recipient, upon giving notice to the department and to the recipient. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 7 AAC 125.120. Responsibilities of personal care assistant. (a) In the consumer-directed and the agency-based programs, a personal care assistant shall maintain a contemporaneous service record for Medicaid billing for each recipient for whom that assistant provides personal care services. The record must include (1) documentation of tasks performed under the categories of the PCAT authorized services plan, including case notes, frequency, scope, and duration; (2) any changes in the recipient’s PCAT authorized services plan prepared under 7 AAC 125.020 and approved by the department; (3) a copy of the PCAT authorized services plan signed by, or bearing the legal mark of, the recipient or the recipient’s legal representative and the department or its designee; (4) a time sheet recording the date, time, and length of each visit and the services provided during each visit; and (5) the signature or legal mark of the recipient or the recipient’s legal representative on each time sheet, verifying that services were provided as reported by the personal care assistant. (b) If a recipient changes personal care assistants or discontinues personal care services, the former personal care assistant shall deliver the record required by (a) of this section to the appropriate personal care agency no more than two days after the date of the change or discontinuation. (c) If a personal care assistant terminates employment, the personal care assistant shall deliver the record required by (a) of this section to the appropriate personal care agency no more than two days after the date of termination. (d) A personal care assistant may not (1) accept payment in any form from a recipient for any Medicaid-reimbursable service; or (2) solicit clients for personal care services. (e) A personal care assistant shall keep all information concerning a recipient confidential in accordance with P.L. 104-191 (Health Insurance Portability and Accountability Act of 1996). (f) A personal care assistant is subject to the reporting requirements of AS 47.17.020 and AS 47.24.010. (g) If a personal care assistant is charged with, convicted of, found not guilty by reason of insanity for, or adjudicated as a delinquent for, a barrier crime listed in 7 AAC 10.905, (1) the personal care assistant shall inform the personal care agency no more than 24 hours, or no later than close of business the next business day, whichever is sooner, after the date that the personal care assistant was charged, convicted, found not guilty by reason of insanity, or adjudicated as a delinquent; and (2) the personal care agency shall notify the department as required under 7 AAC 10.925(b). (h) A personal care assistant shall notify the personal care agency no more than


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10 days after a change in the personal care assistant’s (1) name; (2) license, certification, or registration status; or (3) mailing address, physical address, or telephone number. (i) In this section, "case notes" means progress notes documented after services are provided that (1) include how the recipient responded to care; (2) identify any changes, improvement, or decline in the recipient’s health, safety, or welfare, including changes in physical or mental conditions; and (3) are dated, signed by a personal care assistant, and contained in the recipient’s service record. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.05.320 AS 47.07.030 AS 47.05.310 AS 47.05.340 7 AAC 125.130. Consumer-directed personal care program; personal care agencies. (a) A consumer-directed personal care agency shall, in addition to meeting the requirements under 7 AAC 125.010 - 7 AAC 125.199, review a recipient’s needs semiannually in the recipient’s home. If the recipient resides in a community not accessible by road or air service, a consumer-directed personal care agency shall arrange for telephone, radio, or, if feasible, in-person contact with the recipient and the personal care assistant to the extent allowed by the recipient’s PCAT authorized services plan and the condition of the recipient, and request that the department waive the residence visitation requirements of this section if necessary. If the semiannual in-person visitation is waived, an in-person visitation must occur annually. (b) As an employer, an agency shall collect and verify consumer-directed personal care assistants’ time sheets and submit claims to the department. Individual personal care assistants employed by an agency are not responsible for submitting their own claims. (c) Before the agency submits the application materials required under 7 AAC 125.060, the administrator of a personal care agency in the consumer-directed program shall attend a department orientation. (d) A newly employed administrator of an existing consumer-directed program shall attend a department orientation no more than six months after the date of hire by the personal care agency, if the department does not have documentation that any other current employee of the personal care agency has attended a mandatory department orientation. (e) A recipient who, because of lack of capacity under 7 AAC 125.140(a), has been terminated from the consumer-directed program by the consumer-directed agency that has been providing services to the recipient is eligible to transfer to, and to receive personal care services through, an approved personal care agency in the agency-based program. Except as provided in 7 AAC 125.110, and at least 30 days before the date of termination, the agency terminating services to a recipient shall give the recipient written notice of the termination and of the recipient’s eligibility to apply to the department for inclusion in the agency-based program. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030


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7 AAC 125.140. Consumer-directed personal care program; recipient requirements. (a) To qualify for personal care services from a consumer-directed program, a recipient must have a health-related condition that results in the need for personal care services, and either the recipient or the recipient’s legal representative must be capable and willing to (1) supervise the personal care assistant; (2) demonstrate a capacity for making choices about ADL under 7 AAC 125.030, understand the impact of those choices, and assume the responsibility of those choices; (3) designate a consumer-directed personal care agency as responsible to fulfill the responsibilities of 7 AAC 125.130 on behalf of the recipient; (4) cooperate with the department staff or designee in the review of the recipient’s PCAT; (5) cooperate with the department staff or designee, and with other state and federal oversight agencies, in conducting compliance reviews, investigations, or audits; (6) negotiate a recipient contract with the consumer-directed personal care agency; (7) specify the training requirements of the personal care assistant and assure that the specified training has been received; and (8) obtain a physician’s, a physician assistant’s, or an advanced nurse practitioner’s prescription regarding the recipient’s home exercise or range-of-motion program under 7 AAC 125.030(a)(3)(G) or (b). (b) A recipient or the recipient’s legal representative (1) is primarily responsible for the scheduling, training, and supervising of the personal care assistant; and (2) has the right to terminate the personal care assistant providing services to that recipient. (c) A recipient’s legal representative must be (1) an unpaid care provider involved in the day-to-day care of the recipient; and (2) managing the recipient’s care, and capable of evaluating the care, as it occurs in the home. (d) A recipient or a recipient’s legal representative must notify the personal care agency no more than five days after the date that the service needs of the recipient change or the name or the address of the recipient or the recipient’s legal representative changes. (e) If a recipient is found to be cognitively incapable of managing the recipient’s own care as shown in the PCAT, the recipient may receive personal care services from an agency-based program only. To receive or continue receiving personal care services from a consumer-directed program, a recipient must obtain a legal representative or submit, on a form provided by the department, documentation from a licensed medical provider stating that the recipient is able to meet the requirements for managing the recipient’s own care. (f) For the purposes of this section, "licensed medical provider" includes a tribal health care provider who is employed by the federal government, assigned to a tribal health program, and licensed to practice in any jurisdiction. (Eff. 2/1/2010, Register 193)


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Authority: AS 47.05.010 AS 47.07.030 7 AAC 125.150. Agency-based personal care program; personal care agencies. (a) A personal care agency in the agency-based program may provide personal care services for a recipient who does not yet have a PCAT authorized services plan approved by the department under 7 AAC 125.020, if the recipient (1) is being or has been discharged from a general acute care hospital or a nursing facility; (2) has a discharge plan or a physician’s confirmation of diagnosis and request for personal care services to begin immediately upon discharge from a general acute care hospital or a nursing facility, and home health services are not available or indicated; and (3) has a plan to have an assessment done by the department or its designee no more than three days after discharge from a general acute care hospital or nursing facility; the three-day period may be extended if the department or its designee is not available to conduct the assessment during the three-day period. (b) A personal care agency in the agency-based program may provide personal care services for a recipient who does not yet have a PCAT authorized services plan approved by the department under 7 AAC 125.020, if the recipient’s primary caregiver is absent due to an emergency and lack of personal care services will result in immediate hospitalization or placement in a nursing facility. The recipient must have an assessment done by the department or its designee no more than three days after the emergency caregiver absence occurs. The three-day period may be extended if the department or its designee is not available to conduct the assessment during the three-day period. (c) A personal care agency in the agency-based program may deny an application for employment of a personal care assistant for any reason subject to sanction under 7 AAC 105.400. (d) Before the agency submits the application materials required under 7 AAC 125.060, the administrator of a personal care agency in the agency-based program shall (1) attend a department orientation; (2) establish the agency’s policy on termination of services to be provided to recipients; and (3) establish a grievance procedure for employees. (e) A newly employed administrator of an existing agency-based program shall attend a department orientation no more than six months after the date of hire by the personal care agency, if the department does not have documentation that any other current employee of the personal care agency has attended a mandatory department orientation. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 7 AAC 125.160. Agency-based program; personal care assistant education and training requirements. (a) A personal care assistant in the agency-based program must have and maintain a valid certificate in first aid and cardiopulmonary resuscitation (CPR) issued by the American Red Cross, American Heart Association, or other agency approved by the department. A personal care assistant must also (1) hold an active license as a nurse in this state under AS 08.68;


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(2) hold an active certification as a certified nurse aide in this state under AS 08.68; (3) hold an active certification as a community health aide III or IV or a community health practitioner by the Alaska Community Health Aide Program Certification Board; (4) have satisfactorily completed training as specified in (b) of this section and passed a standardized competency test approved by the department; or (5) have had training or experience equivalent to the training specified in (b) of this section during the five-year period immediately preceding application to work in the program, and passed a standardized competency test approved by the department. (b) Training referred to in (a)(4) or (5) of this section must be approved by the department, must be provided by a nurse licensed under AS 08.68, and must provide at least 40 hours of instruction in the following subject areas: (1) infection control in the home; (2) bowel and bladder care; (3) basic nutrition and food planning and preparation; (4) procedures for physical transfers, including emergency evacuation of physically disabled persons and nonambulatory persons; (5) assistance with self-administered medication; (6) procedures for taking blood pressure, temperature, pulse, and respiration; (7) understanding and working with children, the elderly, persons with physical or developmental disabilities, persons with communicable diseases, and persons with physical or mental illnesses; (8) practical knowledge of body systems, body mechanics, body disorders and diseases, and the observation of body functions; (9) death and dying; (10) practical skills and use of equipment necessary to perform tasks identified in 7 AAC 125.030(a)(1); (11) legal requirements affecting personal care assistants, including record keeping under 7 AAC 105.230, confidentiality, personal care assistant program responsibilities as set out in 7 AAC 105 - 7 AAC 160, medical assistance fraud under AS 47.05.210, and reporting of harm under AS 47.17.020 - 47.17.022 and AS 47.24; (12) universal precautions; for purposes of this paragraph, "universal precautions" means the infectious control precautions that are recommended by the United States Department of Health and Human Services, Centers for Disease Control and Prevention to be used to prevent the transmission of blood-borne germs such as human immunodeficiency virus and hepatitis B virus; (13) infection control. (c) The department may allow payment for services provided by an individual who has performed duties similar to those of a personal care assistant under 7 AAC 125.010 - 7 AAC 125.199, has completed at least 16 hours of training in the areas listed in (b) of this section, and whose job performance has been found satisfactory by the appropriate personal care agency, based upon references or other verification, but whose training does not meet the requirements of this section, if that individual (1) is otherwise qualified to act as a personal care assistant under 7 AAC


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125.090; (2) provides proof of enrollment in training that, no more than four months after beginning employment as a personal care assistant, will qualify the individual to meet the requirements of (b) of this section; and (3) ensures that the personal care agency provides proof that the individual has successfully completed the 16 hours of training required under this subsection to enable that individual to be eligible for payment as a personal care assistant. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 7 AAC 125.170. Agency-based personal care program; supervising registered nurse. (a) A personal care agency in the agency-based program shall retain a supervising registered nurse, licensed under AS 08.68, to perform the following duties: (1) obtain from the department prior authorization to implement the PCAT authorized services plan for each recipient; (2) at least once every six months perform, or supervise the performance of, a review of the recipient’s services, including

(A) interviewing the recipient at the recipient’s residence to assure services are provided and meeting the recipient’s needs; (B) evaluating the service records, including time sheets prepared by the recipient’s personal care assistant; (C) verifying in writing that the services provided are consistent with the recipient’s PCAT authorized services plan; (D) determining whether progress is being made toward achieving the service goal; and (E) notifying the department of any recommended changes in the number of personal care service hours and the reasons for the recommended changes;

(3) if the recipient resides in a community not accessible by road or air service, arrange for telephone, radio, or, if feasible, in-person contact with the recipient and the personal care assistant to the extent allowed by the recipient’s PCAT authorized services plan and the condition of the recipient, and request that the department waive the residence visitation requirements of this section if necessary; if the six-month, in-person visitation is waived, an in-person visitation must occur annually; (4) put written provisions in the recipient’s file for emergency situations that the personal care assistant may encounter; (5) maintain communications with the recipient, the recipient’s physician, if any, and the personal care assistant; (6) maintain a service record for each recipient that includes a

(A) copy of each PCAT authorized services plan, assessment, and evaluation made for the duration of care including changes made under 7 AAC 125.020; (B) copy of the personal care assistant’s time sheets; and (C) record of all contacts with the recipient, the recipient’s health care provider, if any, and the personal care assistant.

(b) A supervising registered nurse under (a) of this section is subject to the


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reporting requirements of AS 47.17.020 and AS 47.24.010. (c) For purposes of this section, "supervising" means implementing and overseeing the PCAT authorized services plan for a recipient in accordance with this section. A supervising nurse is not required to perform administrative or personnel functions such as hiring, disciplining, scheduling, or terminating a personal care assistant. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 7 AAC 125.180. Review and appeal rights. (a) A recipient who is terminated from a consumer-directed or agency-based program may challenge that termination through the agency’s grievance procedure, as the agency documented that procedure in the application materials required under 7 AAC 125.060. (b) If the PCAT shows that an individual is not capable of managing consumer-directed services because of a lack of capacity as provided in 7 AAC 125.140, or if a person is terminated from a consumer-directed program because the individual lacks capacity to manage personal care services, the individual may appeal that decision under 7 AAC 49. (c) If a service authorized by the PCAT authorized services plan is reduced, terminated, or denied, the recipient may appeal that decision under 7 AAC 49. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 7 AAC 125.190. Consumer-directed and agency-based personal care programs; compliance reviews. In both the consumer-directed and agency-based programs, the department, with recipient participation, will conduct compliance reviews of the personal care agencies on a biennial basis and at other times determined necessary by the department. The reviews must include evaluation of (1) service delivery; (2) service authorization; (3) records maintenance; (4) financial accountability; and (5) recipient satisfaction. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 7 AAC 125.195. Payment for personal care services. (a) The department will only provide Medicaid payment for personal care services that are performed in accordance with 7 AAC 125.010 - 7 AAC 125.199 and applicable federal and state law. (b) The department will base its payment on the tasks specified in the recipient’s approved PCAT authorized services plan under 7 AAC 125.020 and the time authorized by the PCAT authorized services plan for each task, to the extent that the tasks and times are consistent with the recipient’s condition. (c) In the agency-based and consumer-based programs, the total time per task for each week may not exceed the time authorized in the recipient’s PCAT authorized services plan. If the time-per-task activity is provided less than one time per week, the time may not exceed the authorized time per period. (d) The department will pay a personal care agency for providing personal care


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services at the rate identified in 7 AAC 145.500. At least 50 percent of the annual total payment made by the department to a personal care agency for personal care services must be spent on compensation for personal care assistants. (e) A personal care assistant’s rendering provider identification number must be submitted with each claim that the personal care agency submits for Medicaid payment from the department. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 7 AAC 125.199. Definitions. In 7 AAC 125.010 - 7 AAC 125.199, unless the context requires otherwise, (1) "ADL" means activities of daily living; (2) "agency-based program" means a program to provide personal care services to a recipient who is unable to, or who chooses not to, take responsibility for managing those services; (3) "consumer-directed program" means a program to provide personal care services to a recipient who takes, or whose legal representative takes, responsibility for managing those services; (4) "CPR" means cardiopulmonary resuscitation; (5) "health care professional" means a physician, a physician assistant, a nurse practitioner, a registered nurse, an occupational therapist, or a clinical social worker; (6) "IADL" means instrumental activities of daily living; (7) "immediate family member of the recipient" means a relative of the recipient with a duty to support the recipient under state law; (8) "legal representative" means a recipient’s

(A) agent under a power of attorney; (B) parent, if the recipient is a minor; or (C) legal guardian;

(9) "PCAT" means the personal care assessment tool; (10) "PCAT authorized services plan" means the recipient's individualized plan, prepared under 7 AAC 125.020 using the PCAT Authorized Services Plan form, adopted by reference in 7 AAC 160.900, for the provision of personal care services; (11) "personal care assessment tool" means the department’s Consumer Assessment Tool (CAT), adopted by reference in 7 AAC 160.900, combined with the PCAT Authorized Services Plan form, adopted by reference in 7 AAC 160.900; (12) "service animal" means an animal trained to assist a physically or mentally challenged person, and certified by a school or training facility for service animals as having completed that training; (13) "solicitation" means an attempt to encourage a recipient to acquire personal care services directly from a personal care assistant for gain or profit directly by the personal care assistant or the personal care assistant’s employing agency. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 \


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Article 2. Home Health Care Services. Section 300. Home health care provider enrollment 310. Home health care services 320. Requirements for home health care services 399. Definitions 7 AAC 125.300. Home health care provider enrollment. (a) To be eligible for payment under 7 AAC 105 - 7 AAC 160, a home health agency must be (1) certified as a home health agency for the purposes of Medicare in the jurisdiction where home health care services are provided; (2) enrolled as a home health care provider in accordance with 7 AAC 105.210; and (3) enrolled in the jurisdiction where home health care services are provided if providing home health care services out of state. (b) The department will pay the following providers for the following home health services: (1) a public or private organization that meets the requirements of (a) of this section may provide comprehensive home health services identified in 7 AAC 125.310(a); (2) a rural health clinic or federally qualified health center enrolled under 7 AAC 140.200 may provide limited home health care services identified in 7 AAC 125.310(a)(2). (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 125.310. Home health care services. (a) The department will pay a public or private home health agency for the following home health care services, if recommended by a licensed physician as part of a plan of care developed in accordance with 7 AAC 125.320: (1) the following services if they are provided to a recipient in the recipient’s place of residence by a public or private organization that the department has certified as a home health agency for purposes of Medicare:

(A) intermittent or part-time skilled nursing services that are provided by a registered nurse or a licensed practical nurse, under the continued direction of the recipient’s physician, and within the scope of the nurse’s license; (B) home health aide services that are prescribed by and under the continued direction of a physician and supervised by a registered nurse; (C) supplies suitable for use in the home; (D) physical therapy, occupational therapy, speech-language pathology services, and audiology services that are prescribed by a physician and provided to a recipient by or under the supervision of a qualified practitioner;

(2) skilled nursing services, at a payment rate determined under 7 AAC 145.700 - 7 AAC 145.730, if

(A) they are provided by a rural health clinic enrolled under 7 AAC 140.200; (B) they are provided to a recipient by a registered nurse who


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receives written orders from the recipient’s physician, and those services are within the scope of the nurse’s license; (C) the location of the recipient’s place of residence is not served by any public or private organization that the department has certified as a home health agency for purposes of Medicare; and (D) the recipient is homebound under 7 AAC 140.220.

(b) For purposes of this section, a place of residence (1) includes an assisted living home licensed under AS 47.32; and (2) does not include a hospital, skilled nursing facility, or intermediate care facility. (c) The department will not set a period longer than 60 days for prior authorization for payment of home health care services. (d) The department will pay a home health agency for home health care services provided to a recipient who is eligible for Medicare, if on the basis of one or more of the following exclusions, Medicare will not pay for some or all of the home health care services ordered by the physician: (1) the recipient does not need intermittent or part-time skilled nursing services; (2) the recipient is not confined to the home. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 125.320. Requirements for home health care services. (a) The department will not pay for a home health care service, other than an initial visit for evaluation purposes, unless the provider has received prior authorization from the department. The department will accept a request for a home health evaluation received from any person concerned with the care of the recipient. (b) A home health agency must submit a request for prior authorization on a form provided by the department, and must include a written statement from the attending physician that (1) explains the need for home health care services, including the reason services cannot be performed in a clinic, outpatient setting, or physician’s office; and (2) includes medical recommendations for a plan of care developed under (d) of this section for services provided

(A) on an ongoing basis; or (B) after acute care; for services provided under this subparagraph, the written statement must include the expected decrease in need for skilled nursing services and home health aide visits.

(c) The department will not determine eligibility to receive home health care services based upon the recipient’s (1) need for institutional care; (2) discharge from institutional care; (3) homebound status, except as provided in 7 AAC 125.310(a)(2); or (4) need for skilled nursing services. (d) A physician shall develop a plan of care for a recipient of home health care services. The plan of care must include


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(1) pertinent diagnoses, including mental status; (2) types of services and equipment required; orders for therapy services must include the specific procedures and modalities to be used and the amount, frequency, and duration of those services; (3) the frequency of visits; (4) the prognosis for the recipient; (5) an analysis of the recipient’s rehabilitation potential; (6) a description of the recipient’s functional limitations; (7) activities permitted to the recipient; (8) the recipient’s nutritional requirements; (9) the recipient’s medications and treatments; (10) any safety measures to protect the recipient against injury; and (11) instructions for a timely discharge and referral. (e) If a physician refers a recipient under a plan of care that cannot be completed until after an evaluation visit, the physician shall make additions or modifications to the original plan of care as necessary to reflect the outcome of the evaluation. (f) To determine the immediate care and support needs of the recipient, and except as provided in (h) of this section, a registered nurse shall complete an initial assessment of the recipient no more than 48 hours after the referral, no more than 48 hours after the recipient’s return to the recipient’s place of residence, or on the physician-ordered start-of-care date. (g) Consistent with the recipient’s immediate care and support needs, and except as provided in (h) of this section, a registered nurse shall complete a comprehensive assessment of the recipient no later than five days after the date care starts. The comprehensive assessment must include a review of each medication that the recipient currently uses in order to identify (1) significant side effects, significant drug interactions, and potential adverse effects and drug reactions; (2) ineffective drug therapy; (3) duplicate drug therapy; and (4) noncompliance by the recipient with drug therapy. (h) If speech-language pathology, physical therapy, or occupational therapy is the only service ordered by the physician, (1) a speech-language pathologist, physical therapist, or occupational therapist, as appropriate, may complete the initial and comprehensive assessments within the scope of the professional’s license; and (2) the department will not require a medication review as part of the comprehensive assessment under (g) of this section. (i) The attending physician shall review the plan of care, initial assessment, and comprehensive assessment (1) at least once during the prior authorization period established under 7 AAC 125.310(c); (2) more frequently if a significant change occurs in the recipient’s condition; and (3) if a discharge of the recipient and return to the same home health agency occurs during a prior authorization period established under 7 AAC 125.310(c).


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(j) At least annually, a physician shall review a recipient’s need for supplies. The department may require more frequent physician reviews for particular prescribed items. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 125.399. Definitions. In 7 AAC 125.300 - 7 AAC 125.399, unless the context requires otherwise, (1) "intermittent or part-time" means no more than eight hours of care, not necessarily consecutive, in a 24-hour period; (2) "skilled nursing services" means the curative, restorative, or preventive aspects of patient care services

(A) performed by a registered nurse or by a licensed practical nurse under the supervision of a registered nurse; and (B) emphasizing a high level of nursing direction, observation, and skill. (Eff. 2/1/2010, Register 193)



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Chapter 130. Medicaid Coverage; Home and Community-Based Waiver Services Article 1. Home and Community-Based Waiver Services; Residential Psychiatric Treatment

Center Level of Care (7 AAC 130.100 - 7 AAC 130.199) 2. Home and Community-Based Waiver Services; Nursing Facility and ICF/MR Level

of Care (7 AAC 130.200 - 7 AAC 130.319)

Article 1. Home and Community-Based Waiver Services; Residential Psychiatric Treatment Center Level of Care.

Section 100. Purpose 105. Recipient eligibility 110. Recipient enrollment and disenrollment for FASD/SED waiver services 115. FASD/SED waiver services 120. FASD/SED waiver plan-of-care standards 125. Provider endorsement 130. Plan-of-care development and coordination services 135. Professional and paraprofessional training and consultation services 140. Treatment and intervention mentor services 145. FASD/SED day habilitation services 150. FASD/SED residential habilitation services 155. Community transition services 160. Supported-employment development services; supported-employment ongoing

services 165. FASD/SED respite care services 199. Definitions 7 AAC 130.100. Purpose. The purpose of 7 AAC 130.100 - 7 AAC 130.199 is to offer a severely emotionally disturbed child who is diagnosed with, recognized as having, or suspected to have a fetal alcohol spectrum disorder an opportunity to receive FASD/SED waiver services in the child’s home or community as an alternative to living in a residential psychiatric treatment center. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.045 7 AAC 130.105. Recipient eligibility. (a) To be eligible for FASD/SED waiver services, an applicant must submit an application for those services to the department. The department will review the application and may request additional documentation as necessary to verify that the applicant meets the requirements of (b) of this section. (b) To be eligible for FASD/SED waiver services, an applicant must (1) be less than 21 years of age; (2) be eligible for Medicaid coverage under 7 AAC 100; (3) reside in or meet the criteria for admission to a residential psychiatric treatment center under 7 AAC 140.405; (4) be determined by the department to require care in a residential psychiatric treatment center for more than 30 days if the applicant did not receive FASD/SED waiver services;


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(5) be (A) diagnosed with a fetal alcohol spectrum disorder; or (B) recognized as having or suspected to have a fetal alcohol spectrum disorder, as determined under (d) of this section, following an assessment

(i) conducted by a multidisciplinary diagnostic team approved by the department; or (ii) that uses a diagnostic process that the department determines is reasonable or equivalent to an assessment under (i) of this subparagraph; and

(6) be determined by the department to require a minimum of one FASD/SED waiver service identified in 7 AAC 130.130 - 7 AAC 130.199 at least one time per month for a fetal alcohol spectrum disorder, in addition to mental health clinic or rehabilitation services provided under 7 AAC 43.470. (c) Subject to the limitation imposed upon the department under 7 AAC 130.110, if the department determines that enough endorsed providers of FASD/SED waiver services are available within the state for the department to expand services to more recipients, the department will expand enrollment to an applicant who has not had a diagnosis or assessment under (b)(5) of this section, but who is suspected to have a fetal alcohol spectrum disorder under (d) of this section. (d) For the purposes of this section, a child is recognized as having or suspected to have a fetal alcohol spectrum disorder if a treating provider’s medical record documents that the (1) child’s mother is known to have or is suspected to have consumed alcohol while pregnant with the child; and (2) child presents one or more of the following characteristics for which the consumption of alcohol as described in (1) of this subsection is considered to be a primary contributing factor:

(A) a cognitive or behavioral disability; (B) a developmental age that appears significantly less than the child’s chronological age; (C) difficulty with abstract thinking or judgment; (D) difficulty with memory, learning, or information processing; (E) difficulty with social skills, social cues, and interacting with peers; (F) difficulty with verbal receptive and expressive language processing.

(e) The department will not pay for an FASD/SED waiver service provided to an applicant (1) while that applicant is an inpatient of a nursing facility, general acute care hospital, or ICF/MR; (2) residing in a residential psychiatric treatment center, except as provided under 7 AAC 130.130 and 7 AAC 130.155 in preparation for transition out of the residential psychiatric treatment center; (3) whose need for home and community-based waiver services, supports, devices, or supplies may be provided for entirely by Medicaid services under 7 AAC 43


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and 7 AAC 105 - 7 AAC 160 without the need for services under 7 AAC 130.100 - 7 AAC 130.199; or (4) who is receiving home and community-based waiver services under 7 AAC 130.200 - 7 AAC 130.319. (f) FASD/SED waiver services under 7 AAC 130.100 - 7 AAC 130.199 are provided in addition to Medicaid services under 7 AAC 43 and 7 AAC 105 - 7 AAC 160, excluding services under 7 AAC 130.200 - 7 AAC 130.319. (g) If the department determines an applicant is eligible under this section, the department will send written notice to the applicant requesting confirmation that the applicant wants the department to pursue enrollment under 7 AAC 130.110. The department will not pursue enrollment under 7 AAC 130.110 until the applicant submits written confirmation on a form provided by the department. If the department determines the applicant is not eligible under this section, the department will notify the applicant in writing of the applicant’s right to appeal that decision under 7 AAC 49. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.045 7 AAC 130.110. Recipient enrollment and disenrollment for FASD/SED waiver services. (a) If an applicant is determined eligible and has requested enrollment under 7 AAC 130.105, the department will confirm that offering FASD/SED waiver services will not bring the department out of compliance with the terms of the waiver approved under 42 U.S.C. 1396n(c) and sec. 6003, P.L. 109-171 (Deficit Reduction Act of 2005) by exceeding (1) the number of recipients approved to receive FASD/SED waiver services; or (2) the average per capita expenditure limit on FASD/SED waiver services. (b) If the department determines enrollment of an applicant will not cause the department to be out of compliance under (a) of this section, the department will send written notice to the applicant of the department’s intent to enroll the applicant in FASD/SED waiver services and begin developing an FASD/SED waiver plan of care. No later than 10 days following the date of the notice, the applicant must inform the department which one of the following options the applicant chooses to receive: (1) Medicaid services in a residential psychiatric treatment center; (2) FASD/SED waiver services instead of Medicaid services in a residential psychiatric treatment center; (3) alternative services provided in the applicant’s community; (4) no Medicaid services. (c) If the applicant has accepted FASD/SED waiver services under (b) of this section, the department will (1) enroll the applicant; (2) notify the office in the department responsible for maintaining the recipient’s Medicaid eligibility under 7 AAC 100; (3) verify that the providers chosen by the recipient are endorsed under 7 AAC 130.125 and available to begin services; and (4) facilitate the start of FASD/SED waiver services by informing


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(A) the discharge planner for the residential psychiatric treatment center the recipient will be leaving, if the recipient is already in a residential psychiatric treatment center; and (B) the providers identified in (3) of this subsection that the child is enrolled.

(d) The department will not enroll an applicant for FASD/SED waiver services or will terminate enrollment of a recipient for FASD/SED waiver services if (1) the applicant or recipient is no longer eligible for Medicaid coverage under 7 AAC 100; (2) the applicant or recipient no longer meets the FASD/SED waiver eligibility requirements of 7 AAC 130.105; (3) continued enrollment of the recipient causes the department to exceed the requirements of (a) of this section; (4) the recipient or the recipient’s representative chooses to end use of FASD/SED waiver services; (5) the department terminates the state’s participation in the demonstration project under sec. 6063, P.L. 109-171 (Deficit Reduction Act of 2005) or elects not to offer FASD/SED waiver services under the authority of 42 U.S.C. 1396n(c); (6) the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services terminates the state’s authority to offer FASD/SED waiver services under sec. 6063, P.L. 109-171 (Deficit Reduction Act of 2005); (7) the applicant’s or recipient’s representative fails to

(A) take an action or submit documentation as required in 7 AAC 130.100 - 7 AAC 130.199; or (B) cooperate with the delivery of services under 7 AAC 130.100 - 7 AAC 130.199;

(8) there is a sustained pattern of the recipient placing caregivers at risk of physical injury while providing services to the recipient under 7 AAC 130.100 - 7 AAC 130.199; (9) the recipient no longer needs the amount or frequency of services offered under 7 AAC 130.100 - 7 AAC 130.199; or (10) the department has determined that the applicant or recipient does not have or is not suspected to have a fetal alcohol spectrum disorder. (e) To document that a recipient’s representative has failed to cooperate with the delivery of services or that the recipient has placed a caregiver at risk of physical injury, a provider must document, to the department’s satisfaction, that the provider has made or attempted to make reasonable accommodation to a person’s disability. A provider’s record must be available to the department for inspection. (f) If the department determines an applicant ineligible for FASD/SED waiver services, does not enroll an applicant for FASD/SED waiver services, or disenrolls a recipient for FASD/SED services under this section, the applicant or recipient may appeal the department’s action under 7 AAC 49. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.045 7 AAC 130.115. FASD/SED waiver services. (a) FASD/SED waiver services described in 7 AAC 130.130 - 7 AAC 130.199 are subject to 7 AAC 105.200 - 7 AAC


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105.490 and 7 AAC 160.100 - 7 AAC 160.140. (b) The department will not pay for FASD/SED waiver services provided to a recipient by (1) the recipient’s parent; (2) a sibling of the recipient, if the sibling is a minor; or (3) the recipient’s spouse. (c) The department will not pay for FASD/SED waiver services provided by the recipient’s guardian, unless (1) a court has authorized the guardian to provide those services under AS 13.26.145(c); and (2) the guardian is employed by a FASD/SED waiver provider endorsed under 7 AAC 130.125. (d) The department will pay for a FASD/SED waiver service only if that service (1) is identified in the recipient’s plan of care under 7 AAC 130.120; (2) is offered by a provider who meets the requirements of 7 AAC 130.125; and (3) has received prior authorization by the department. (e) Notwithstanding the provisions of 7 AAC 130.120 and 7 AAC 130.130, the department may elect to perform the FASD/SED waiver plan-of-care coordination for a specific applicant or recipient. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.045 7 AAC 130.120. FASD/SED waiver plan-of-care standards. (a) If a recipient has been enrolled under 7 AAC 130.110, the department will authorize the development of an FASD/SED waiver plan of care. The department will pay for FASD/SED waiver services covered under 7 AAC 130.100 - 7 AAC 130.199 only if those services are identified in the plan of care. (b) An FASD/SED waiver plan of care (1) may not include home and community-based waiver services under 7 AAC 130.200 - 7 AAC 130.319; (2) must be developed in conjunction with a treatment plan developed for other community mental health services under 7 AAC 43.728; (3) may not duplicate or conflict with a personal care assessment tool (PCAT) service plan under 7 AAC 125.020. (c) An FASD/SED waiver plan of care must be prepared in writing by an endorsed FASD/SED waiver services provider in accordance with 7 AAC 43.470 and must include (1) a list of services necessary to treat the impairments identified in a functional assessment using the Child and Adolescent Functional Assessment Scale, by Kay Hodges, Ph.D., adopted by reference in 7 AAC 160.900; (2) a description of family and community supports; (3) a description of how the plan of care developed under this section will supplement and not duplicate services provided under any existing plan of care applicable to the recipient; (4) a list of the specific FASD/SED waiver services the recipient needs, including the selected providers, number of units of services, frequency of services, and


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dates of service; (5) clearly stated and measurable objectives derived from the assessments and designed to accomplish specific, observable changes in skills, symptoms, or behaviors; (6) a list of the specific interventions that are designed to accomplish the stated goals or objectives; (7) appropriate documentation that describes and supports the recipient’s request and need for FASD/SED waiver services; and (8) the contingency plan required under 7 AAC 130.130(b)(4). (d) Before the submission of a plan of care to the department for consideration and approval, the recipient or recipient's representative must indicate by signature that the recipient is in agreement with the plan of care. (e) The department will approve an FASD/SED waiver plan of care if the department determines that each service listed in the plan of care, when combined with the recipient’s mental health services provided under 7 AAC 43.470, is of sufficient amount, duration, and scope to prevent, with reasonable certainty, the recipient from requiring admission to a residential psychiatric treatment center. (f) A recipient's need for FASD/SED waiver services must be reviewed semi-annually, unless the department determines that an earlier review is necessary due to changes in the recipient’s health or other life circumstances that affect the recipient’s ability to benefit from FASD/SED waiver services. An FASD/SED waiver plan-of-care coordination services provider shall prepare a new plan of care that meets the requirements of (c) of this section and present a new assessment and any recommended changes in the plan of care to the department for approval. The department will approve the revised plan of care in accordance with (e) of this section. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.045 7 AAC 130.125. Provider endorsement. (a) The department will pay a provider for providing an FASD/SED waiver service only if the provider who is submitting to the department a claim for payment is (1) enrolled in the Medicaid program under 7 AAC 105.210; and (2) endorsed by the department under this section to provide the service for which the provider is submitting the claim for payment. (b) To be endorsed by the department to provide FASD/SED waiver services, a provider must attest that the provider has participated in FASD/SED waiver services training, if training is available through the department. In addition, the provider must be enrolled as (1) a community mental health clinic under 7 AAC 43.725(a)(1) that

(A) is accredited as a children’s service provider by (i) the Council on Accreditation (COA); (ii) the Commission on Accreditation of Rehabilitation Facilities (CARF); or (iii) The Joint Commission; or

(B) attests to meeting the requirements for (i) restraint and seclusion, including drug use as a restraint,


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under 42 C.F.R. 483.350 - 483.376, adopted by reference in 7 AAC 160.900; and (ii) administration of medication under 12 AAC 44.965, adopted by reference in 7 AAC 160.900; or

(2) a home and community-based waiver services provider under 7 AAC 130.220 that attests to meeting the requirements for

(A) restraint and seclusion, including drug use as a restraint, under 42 C.F.R. 483.350 - 483.376, adopted by reference in 7 AAC 160.900; and (B) administration of medication under 12 AAC 44.965, adopted by reference in 7 AAC 160.900.

(c) Providers meeting the requirements of (b)(1) of this section may provide the services identified in 7 AAC 130.130 - 7 AAC 130.199. (d) Providers meeting the requirements of (b)(2) of this section may provide the services identified in 7 AAC 130.135 and 7 AAC 130.145 - 7 AAC 130.199. (e) The department will review an FASD/SED waiver services provider each year. If at the conclusion of the review the department finds that the FASD/SED waiver services provider continues to meet the requirements of 7 AAC 130.100 - 7 AAC 130.199, the department will extend the provider’s endorsement for one year. (f) The department may remove an FASD/SED waiver services provider’s endorsement, or will not endorse a provider to provide FASD/SED waiver services, (1) if the department determines that the provider no longer meets the requirements of (a) or (b) of this section; or (2) for grounds or under procedures set out in 7 AAC 105.400 - 7 AAC 105.490. (g) If the department decides not to endorse a provider under this section, the provider may appeal the decision under 7 AAC 105.460. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.045 7 AAC 130.130. Plan-of-care development and coordination services. (a) The department will pay an FASD/SED waiver services provider endorsed under 7 AAC 130.125 for plan-of-care development and coordination services under this section if those services are provided by a mental health professional clinician or a mental health associate clinician under the direction of a mental health professional clinician. (b) FASD/SED waiver plan-of-care development services include (1) coordinating the individuals who should participate in the development of the individualized FASD/SED waiver plan of care, including members of a fetal alcohol spectrum disorder diagnostic team if a team is available in the applicant’s or recipient’s community; (2) writing the final individual FASD/SED waiver plan of care; (3) conducting the assessment under 7 AAC 130.120(c)(1), or having a treatment and intervention mentor conduct that assessment as provided in 7 AAC 130.140(b)(10); and (4) developing a contingency plan

(A) to cover times when FASD/SED waiver services providers are temporarily unable to meet the needs of the recipient; and (B) that identifies alternative services, supports, or individuals


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who are available to support the recipient in an emergency. (c) FASD/SED waiver plan-of-care coordination services include (1) documenting all revisions to the FASD/SED waiver plan of care; (2) reviewing the FASD/SED waiver plan of care in accordance with 7 AAC 130.120(f) and modifying the plan of care in accordance with this section as needed; (3) recommending any changes that need to be made to the FASD/SED waiver plan of care; (4) monitoring and assessing the delivery of services identified in the FASD/SED waiver plan of care by supervising the delivery of services under 7 AAC 130.140; (5) monitoring and recording the recipient’s progress toward goals identified in the FASD/SED waiver plan of care; and (6) assessing the quality of the FASD/SED waiver plan of care and the quality of the services provided by completing the University of Washington Wraparound Evaluation and Research Team’s Wraparound Fidelity Index 4 (WFI-4), adopted by reference in 7 AAC 160.900. (d) FASD/SED waiver plan-of-care coordination services do not include direct delivery of services to the recipient. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.045 7 AAC 130.135. Professional and paraprofessional training and consultation services. (a) The department will pay for professional training and consultation services under (b) of this section or paraprofessional training and consultation services under (c) of this section only if those services are provided by an FASD/SED waiver services provider who meets the requirements of 7 AAC 130.125. (b) Professional training and consultation services are those services described in (d) of this section that are provided by (1) a mental health professional clinician; (2) a master’s degree-level specialist in developmental disabilities; or (3) an individual licensed medical provider who is employed by or under contract with an FASD/SED waiver services provider endorsed under 7 AAC 130.125. (c) Paraprofessional training and consultation services are those services described in (d) of this section that (1) do not require services of a provider identified in (b) of this section; and (2) are provided by an individual who

(A) provides services within the scope of the individual’s training and experience; and (B) works under the direction of

(i) a mental health professional clinician; (ii) a master’s degree-level specialist in developmental disabilities; or (iii) an individual licensed medical provider who is employed by or under contract with an FASD/SED waiver services provider endorsed under 7 AAC 130.125.


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(d) Professional and paraprofessional training and consultation services are services designed to facilitate implementation and ongoing provision of the recipient’s FASD/SED waiver plan of care, including providing (1) training and consultation on the development of effective transitions, including meeting with individuals who will be involved with the recipient after the transition has occurred; (2) specialized training to individual unpaid caregivers necessary to achieve the purpose of FASD/SED waiver services; (3) supportive interventions to ensure that the family and other caregivers receive the training and assistance needed to implement the recipient’s FASD/SED waiver plan of care; and (4) training and consultation to the FASD/SED waiver plan-of-care coordinator, treatment and intervention mentor, family, and other caregivers as needed and as required to implement and maintain the plan of care. (e) A training and consultation services provider is not authorized to modify a recipient’s FASD/SED waiver plan of care. Modification of a recipient’s FASD/SED waiver plan of care may only occur in accordance with 7 AAC 130.120. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.045 7 AAC 130.140. Treatment and intervention mentor services. (a) The department will pay an FASD/SED waiver services provider for treatment and intervention mentor services under this section if the FASD/SED waiver services provider is endorsed under 7 AAC 130.125 and provides those services to the recipient through a mentor who (1) has achieved a level of education and experience that is equivalent to or greater than a mental health clinical associate; (2) works within the scope of the individual’s training and experience; and (3) works under the direction of a mental health professional clinician or physician. (b) Treatment and intervention mentor services include (1) modeling and participating in activities of daily living; (2) modeling basic social skills; (3) monitoring progress toward goals as identified in the recipient’s FASD/SED waiver plan of care; (4) active participation in FASD/SED waiver plan of care meetings; (5) active involvement with the recipient, recipient’s family or guardian, discharging residential psychiatric treatment center, fetal alcohol spectrum disorder diagnostic team, employers, health care providers, schools, or other caregivers as needed to implement the recipient’s FASD/SED waiver plan of care; (6) active involvement in the recipient’s daily life as needed to

(A) coordinate necessary appointments and monitor follow-up; (B) arrange for basic public or private transportation; and (C) coordinate or schedule all necessary assessments and evaluations as specified in the FASD/SED waiver plan of care;


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(7) informing the plan-of-care coordination services provider when the FASD/SED waiver plan of care may need to be reviewed or modified to ensure the appropriate services are provided to the recipient; (8) monitoring and documenting behavioral changes weekly on a form provided by the department; (9) implementing, if needed, any contingency plan included in the FASD/SED waiver plan of care; and (10) conducting the assessment under 7 AAC 130.120(c)(1). (c) Treatment and intervention mentor services do not include (1) targeted case management; (2) day habilitation; (3) residential habilitation; (4) school-based services; (5) respite services; (6) supported-employment services; or (7) children’s mental health services under 7 AAC 43, 7 AAC 105 - 7 AAC 125, and 7 AAC 140 - 7 AAC 160. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.045 7 AAC 130.145. FASD/SED day habilitation services. (a) The department will pay for day habilitation services provided under this section if the provider is an FASD/SED waiver services provider endorsed under 7 AAC 130.125. (b) Day habilitation services must include activities and environments that are designed to foster (1) acquisition of, retention of, or improvement in self-help, socialization, and adaptive skills that take place in a nonresidential setting, separate from the recipient’s residence; (2) appropriate behavior; (3) greater independence when appropriate; (4) greater interdependence when appropriate; and (5) the reinforcement of skills taught in school, therapy, or other settings. (c) The department will not pay for day habilitation services if those services are provided in the recipient’s residence. (d) Day habilitation services may not replace, enhance, or supplement education services the recipient is eligible for under 7 AAC 52. (e) The department will not pay for day habilitation services provided on the same day as residential habilitation services. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.045 7 AAC 130.150. FASD/SED residential habilitation services. (a) The department will pay for residential habilitation services provided under this section if the provider is a FASD/SED waiver services provider endorsed under 7 AAC 130.125 that is (1) a group or family habilitation home for recipients 18 years of age or older that is licensed as an assisted living home under AS 47.32; (2) a family habilitation home for recipients under 18 years of age that is licensed as a foster home under AS 47.32; or


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(3) a therapeutic family or group home for recipients under 18 years of age that is licensed as a residential child care facility under AS 47.32. (b) Residential habilitation services include teaching or developing in the recipient the following social and adaptive skills necessary to enable the recipient to reside in a non-institutional setting: (1) personal grooming and cleanliness; (2) household chores; (3) eating and preparing food. (c) Residential habilitation services must be authorized by the department and included in the recipient’s FASD/SED waiver plan of care. The FASD/SED waiver plan of care must describe the specific services to be provided and how those services supplement mental health services for recipients provided under 7 AAC 43.450 - 7 AAC 43.471. (d) The department will not pay for the following as a residential habilitation service: (1) room and board; (2) maintenance, upkeep, or improvements to the residential dwelling; (3) modification or adaptation of the residential dwelling; (4) any payment, including an indirect payment, to a member of the recipient’s immediate family; (5) routine care and supervision expected of a parent, family member, or a group home provider; (6) activities or supervision for which a payment is made by a source other than Medicaid. (e) The department will not pay for residential habilitation services provided on the same day as day habilitation services or respite services. (f) In this section, "immediate family" means the parents of a recipient under 18 years of age and the spouse or minor siblings of a recipient under 21 years of age. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.045 7 AAC 130.155. Community transition services. (a) The department will pay for community transition services provided under this section by paying an FASD/SED waiver services provider endorsed under 7 AAC 130.125 who has agreed to pay landlords, utility companies, and other individuals and businesses who are providing community transition services directly to a recipient. (b) Community transition services include (1) security deposits; (2) utility set-up fees or deposits; (3) health and safety assurances such as pest eradication, allergen control, or one-time cleaning immediately before occupancy; (4) moving fees; (5) purchasing furniture; and (6) purchasing basic household items essential for living outside an institution. (c) Community transition services do not include


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(1) payment of monthly lease or rent; (2) food costs; (3) other ongoing costs; (4) recreation or entertainment activities, including the purchase of

(A) television programming or its delivery; (B) computers; (C) Internet connection; (D) entertainment-related consumer electronics, games, or media rentals; or (E) skis or snowboards;

(5) the purchase or lease of motor vehicles, bicycles, or other vehicles; (6) durable medical equipment under 7 AAC 120.200 - 7 AAC 120.299 or specialized medical equipment under 7 AAC 130.305; or (7) environmental modification services under 7 AAC 130.300. (d) The department will pay for community transition services only if (1) the recipient is 17 years of age or older; and (2) the service is part of a transitional independent living plan within the FASD/SED waiver plan of care under 7 AAC 130.120. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.045 7 AAC 130.160. Supported-employment development services; supported-employment ongoing services. (a) The department will pay for supported-employment development services and supported-employment ongoing services provided under this section if those services are provided by an FASD/SED waiver services provider endorsed under 7 AAC 130.125 who is a vocational rehabilitation services provider approved by the Department of Labor and Workforce Development under AS 23.15. (b) Supported-employment development services include (1) identifying a recipient’s individual strengths that can serve as a foundation for individualized job development and customization; (2) benefits counseling; (3) job coaching, including the training necessary to perform job functions and to respond appropriately to social aspects of the job; (4) job modification; (5) transportation between the recipient’s place of residence and the employment site; and (6) services and supports that assist recipients in achieving self-employment through the operation of a business, including

(A) identifying potential business opportunities based upon an assessment of the recipient’s interests and support needs; (B) developing a written business plan, including potential sources of business financing and other assistance in developing and launching a business; (C) developing a list of the physical and behavior supports and the amount of those supports the recipient will need to achieve self-employment; and (D) development and implementation of a long-term support plan that identifies the supports the recipient will need to maintain and grow the recipient’s business.


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(c) Supported-employment ongoing services include (1) ongoing training and supervision necessary to sustain employment; (2) assessment of a recipient’s employment stability and needs; (3) job skills refresher training; (4) social skills training; (5) regular observation at the worksite; and (6) follow-up with the employer, the recipient, and any other person the provider has identified as giving support to the recipient. (d) The department will not pay for (1) an expense associated with starting up or operating a business; (2) supervisory activities rendered as a normal part of the business setting; (3) supported-employment ongoing services provided on the same day as supported-employment development services; or (4) supported-employment services for a recipient less than 14 years of age. (e) A recipient is not eligible to receive supported-employment services under this section if the recipient is eligible for services through 29 U.S.C. 701 - 796l (Rehabilitation Act of 1973) or 20 U.S.C. 1400 - 1482 (Individuals with Disabilities Education Act). (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.045 7 AAC 130.165. FASD/SED respite care services. (a) The department will pay for respite care services provided under this section if those services are provided by an adult employee of an FASD/SED waiver services provider endorsed under 7 AAC 130.125. If respite care services are provided overnight in a location that is not the recipient’s residence, the endorsed provider must be (1) an assisted living home licensed under AS 47.32, if the recipient is 18 years of age or older; (2) a foster home licensed under AS 47.32, if the recipient is under 18 years of age; or (3) a therapeutic family or group home for recipients under 18 years of age that is licensed as a residential child care facility under AS 47.32. (b) The department will consider services to be respite care services if those services provide alternative caregivers, regardless of whether the services are provided in the recipient’s home or at another location, to relieve (1) primary unpaid caregivers, including family members and court-appointed guardians; (2) providers of residential habilitation services under 7 AAC 130.150; (3) foster parents licensed under AS 47.32; or (4) a therapeutic family or group home for recipients less than 18 years of age that is licensed as a residential child care facility under AS 47.32. (c) The department will not pay for respite services to allow a primary caregiver to (1) work outside the home; (2) provide oversight for additional minor children living in the home; or (3) relieve other paid providers of Medicaid services, except for providers


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of residential habilitation services in a foster home. (d) The department will pay for a recipient’s room and board expenses while the recipient is also receiving respite care services if the room and board are provided in one of the following locations that is not the recipient’s residence: (1) an assisted living home licensed under as AS 47.32, if the recipient is 18 years of age or older; (2) a foster home licensed under AS 47.32, if the recipient is less than 18 years of age; (3) a therapeutic family or group home for recipients less than 18 years of age that is licensed as a residential child care facility under AS 47.32. (e) The department will not pay for respite care services provided on the same day as residential habilitation services or supported-employment services. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.045 7 AAC 130.199. Definitions. In 7 AAC 130.100 - 7 AAC 130.199, unless the context requires otherwise, (1) "applicant" means an individual who has applied for FASD/SED waiver services but has not yet been determined eligible for those services; (2) "applicant's representative" means a parent, guardian, or other individual with legal authority to act on the applicant’s behalf; (3) "child" means an individual under 21 years of age; (4) "community transition services" mean payment or payment for the initial cost of establishing a residence in the community; (5) "day habilitation services" means direct assistance with acquisition of, retention of, or improvement in self-help, socialization, and adaptive skills to enable the recipient to reside in a noninstitutional setting; (6) "FASD/SED" means fetal alcohol spectrum disorder/severely emotionally disturbed; (7) "FASD/SED waiver services" means the home and community-based waiver services described in 7 AAC 130.100 - 7 AAC 130.199 that are authorized as part of a demonstration project authorized under sec. 6063, P.L. 109-171 (Deficit Reduction Act of 2005) or a federal waiver under 42 U.S.C. 1396n(c) and that allow a recipient who would otherwise need treatment offered in a residential psychiatric treatment center to live outside of a residential psychiatric treatment center; (8) "FASD/SED waiver services provider" means a Medicaid provider that the department has endorsed under 7 AAC 130.125 to provide one or more FASD/SED waiver services; (9) "fetal alcohol spectrum disorder" means a range of physical, mental, behavioral, or learning disabilities, including fetal alcohol syndrome (FAS), fetal alcohol effects (FAE), alcohol-related neurodevelopmental disorder (ARND), and alcohol-related birth defects (ARBD) that occur in an individual whose mother consumed alcohol while pregnant with the individual; (10) "residential habilitation services" means services that provide direct assistance with acquisition of, retention of, or improvement in skills related to activities of daily living and self-help, social, and adaptive skills necessary to enable the recipient


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to reside in a noninstitutional setting; (11) "respite care services" means services provided to a recipient that allow relief of the recipient’s primary unpaid caregivers; (12) "severely emotionally disturbed" and "severely emotionally disturbed child" have the meaning given "severely emotionally disturbed child" in 7 AAC 43.1990; (13) "supported-employment services" means developmental or ongoing support services that enable the recipient to perform in a regular work setting and without which the recipient would be unlikely to maintain competitive employment at or above the minimum wage because of the recipient’s fetal alcohol spectrum disorder and severe emotional disturbance. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.045

Article 2. Home and Community-Based Waiver Services; Nursing Facility and ICF/MR Level of Care.

Section 200. Purpose 202. Services provided by family members 205. Recipient enrollment and eligibility 210. Recipient disenrollment 220. Provider certification and enrollment 225. Provider disenrollment and decertification 230. Screening, assessment, plan of care, and level-of-care determination 235. Nursing oversight 240. Care coordination services 245. Chore services 250. Adult day services 255. Residential supported-living services 260. Day habilitation services 265. Residential habilitation services 270. Supported-employment services 275. Intensive active treatment services 280. Respite care services 285. Specialized private-duty nursing services 290. Transportation services 295. Meals services 300. Environmental modification services 305. Specialized medical equipment and supplies 310. Restrictions on residential supported-living services payment 319. Definitions 7 AAC 130.200. Purpose. The purpose of 7 AAC 130.200 - 7 AAC 130.319 is to offer a choice between home and community-based waiver services and institutional care to aged, blind, physically or developmentally disabled, or mentally retarded persons who meet the eligibility criteria in 7 AAC 130.205. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.045


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7 AAC 130.202. Services provided by family members. Home and community-based waiver services covered under 7 AAC 130.200 - 7 AAC 130.319 do not include services provided by (1) an immediate family member of a recipient to the recipient; or (2) a guardian to a ward, unless a court has authorized the guardian to provide those services under AS 13.26.145(c). (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.045 7 AAC 130.205. Recipient enrollment and eligibility. (a) Except as provided in 7 AAC 130.100 - 7 AAC 130.199, for the department to make payment under Medicaid for home and community-based waiver services provided to an individual, the (1) individual must be

(A) eligible for coverage under AS 47.07.020, 7 AAC 100.002, and (d) of this section; and (B) enrolled in accordance with (e) of this section; and

(2) services must be provided in accordance with the applicable requirements of 7 AAC 130.200 - 7 AAC 130.319. (b) Home and community-based waiver services are not available to an individual (1) while the individual is an inpatient of a nursing facility, acute care hospital, or intermediate care facility for the mentally retarded (ICF/MR); or (2) if the individual’s need for home and community-based waiver services, supports, devices, or supplies may be provided for entirely by services under 7 AAC 105 - 7 AAC 160 without services identified under 7 AAC 130.200 - 7 AAC 130.319. (c) A recipient enrolled in the home and community-based waiver services program is eligible to receive other Medicaid services for which the recipient is otherwise eligible. (d) For the department to determine an applicant eligible to receive home and community-based waiver services under this section, the applicant must (1) fall into one of the following recipient categories:

(A) children with complex medical conditions; the department will determine an applicant to be a child with a complex medical condition if the applicant

(i) is under 22 years of age; (ii) would receive long-term care in a facility for more than 30 days per year if the applicant did not receive home and community-based waiver services; (iii) has a severe chronic physical condition that results in a prolonged dependency on medical care or technology to maintain health and well-being; (iv) experiences periods of acute exacerbation or life-threatening conditions; (v) needs extraordinary supervision and observation; and (vi) either needs frequent or life-saving administration of


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specialized treatment or is dependent on mechanical support devices; (B) adults with physical disabilities; in this subparagraph, "adult" means an individual at least 21 years of age and less than 65 years of age; (C) individuals with mental retardation and developmental disabilities; (D) older adults; in this subparagraph, "older adult" means an individual 65 years of age or older; and

(2) require a level of care provided in a nursing facility or ICF/MR; the department will base a determination of eligibility under this paragraph on the level-of-care assessment under 7 AAC 130.230(b), and will determine eligibility under

(A) 7 AAC 140.505 - 7 AAC 140.515, if the applicant falls within the recipient category of

(i) children with complex medical conditions; (ii) adults with physical disabilities; or (iii) older adults; or

(B) 7 AAC 140.600, if the applicant falls within the recipient category of individuals with mental retardation and developmental disabilities;

(e) An applicant determined eligible under (a)(1)(A) of this section will be enrolled for home and community-based waiver services if the department determines that enrolling the applicant will not bring the department out of compliance with the terms of the waiver approved under 42 U.S.C. 1396n(c) by exceeding the (1) number of recipients approved for participation in the waiver program for the applicable recipient category; or (2) average per capita expenditure limit on home and community-based waiver services for the applicable recipient category. (f) Except as provided in 7 AAC 130.240, home and community-based waiver services to be provided to a recipient are payable under 7 AAC 130.200 - 7 AAC 130.319 only after the department (1) approves, under 7 AAC 130.230, the plan of care for the recipient; and (2) determines that a home and community-based waiver services provider is available that

(A) is enrolled with the department in accordance with 7 AAC 130.220; and (B) has the capacity to meet the service levels approved under (1) of this subsection as part of the plan of care.

(g) The earliest date that an individual may receive home and community-based waiver services is the first date when all of the requirements in (d) of this section have been met. Except as provided in 7 AAC 130.240, the department will not make payment for services that are payable under (f) of this section unless the recipient is enrolled under (e) of this section. (h) The department will notify an applicant who meets the eligibility requirements of this section that the applicant may choose between home and community-based waiver services and institutional care in a nursing facility or ICF/MR. The applicant’s choice of service must be documented on a form approved by the department. (i) An applicant or recipient who is denied enrollment for home and community-


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based waiver services may appeal that decision under 7 AAC 49. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.045 7 AAC 130.210. Recipient disenrollment. (a) The department will disenroll a recipient for one or more of the following reasons: (1) the recipient is no longer eligible for Medicaid coverage under AS 47.07.020, 7 AAC 100.002, and 7 AAC 130.205(d); (2) the recipient or the recipient’s representative chooses to end use of home and community-based waiver services; (3) the department terminates its participation in the waiver program under 42 U.S.C. 1396n(c); (4) the recipient fails to take an action or submit documentation as required in 7 AAC 130.230; (5) the recipient’s care coordinator, on the behalf of the recipient, fails to take an action or submit documentation as required in 7 AAC 130.230, if the department has provided the recipient with written notice

(A) identifying the action the care coordinator did not take or the documentation the care coordinator did not provide; (B) indicating that the recipient has 30 days to take the action or submit the documentation required; (C) informing the recipient that the recipient may choose a new care coordinator; and (D) indicating whether the department is not willing to assume the duties of care coordination under 7 AAC 130.230(i);

(6) the recipient has a documented history of failing to cooperate with the delivery of services identified in the plan of care prepared under 7 AAC 130.230(c), or of placing caregivers at risk of physical injury; for purposes of this paragraph, a documented history exists if service providers

(A) report that they cannot obtain cooperation with service delivery or eliminate the risk of physical injury to caregivers through reasonable accommodation to a person’s disability; and (B) maintain records to support that report; those records must be available to the department for inspection; the department will review those records before making a decision on disenrollment under this paragraph.

(b) A recipient who is disenrolled from the home and community-based waiver services program, as documented by the department for reasons described in (a) of this section, may appeal that decision under 7 AAC 49. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.045 7 AAC 130.220. Provider certification and enrollment. (a) To be certified by the department as a provider of a home and community-based waiver service, the provider must meet the applicable certification criteria, including provider qualifications and program standards, set out in the department’s Home and Community-Based Waiver Services Certification Application Packet, adopted by reference in 7 AAC 160.900. (b) The department will enroll the following provider types to provide home and


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community-based waiver services if the provider is certified by the department under (a) of this section as a provider of particular home or community-based waiver services, and if the provider has submitted a provider information submission under 7 AAC 105.210: (1) as a home and community-based waiver services provider, for

(A) chore services provided under 7 AAC 130.245; (B) adult day services provided under 7 AAC 130.250; (C) day habilitation services provided under 7 AAC 130.260; (D) residential habilitation services provided under 7 AAC 130.265; (E) supported-employment services provided under 7 AAC 130.270; (F) intensive active treatment services provided under 7 AAC 130.275; (G) respite care services provided under 7 AAC 130.280; (H) transportation services provided under 7 AAC 130.290; (I) meals services provided under 7 AAC 130.295; or (J) environmental modification services provided under 7 AAC 130.300;

(2) as a care coordination agency provider, for care coordination services provided under 7 AAC 130.240; (3) as a residential supported-living services provider, for residential supported-living services provided under 7 AAC 130.255; (4) as a durable medical equipment provider under 7 AAC 120.200 - 7 AAC 120.299, for specialized medical equipment and supplies provided under 7 AAC 130.305, unless the department has awarded a contract to a particular provider to act as the single source of a particular item under 7 AAC 120.200(n); (5) as a private-duty nursing provider under 7 AAC 110.520, for specialized private-duty nursing services provided under 7 AAC 130.285. (c) Notwithstanding (a) of this section, (1) without requiring certification, the department will enroll a contractor licensed under AS 08.18 as a home and community-based waiver services provider, for environmental modification services provided under 7 AAC 130.300, if the

(A) department determines that the contractor is in compliance with the applicable provisions of 7 AAC 130.300; and (B) contractor has submitted a provider information submission agreement under 7 AAC 105.210; and

(2) a provider of transportation that is enrolled under 7 AAC 120.400 - 7 AAC 120.490 to provide transportation under the Medicaid program need not be certified by the department in order to enroll under (b) of this section to provide transportation services under 7 AAC 130.290. (d) If a recipient plans to obtain services out of state, the recipient’s care coordination agency provider must document that the recipient has chosen the out-of-state provider freely, and must have a written agreement with the out-of-state provider setting out the quality assurance responsibilities of the care coordination agency provider and the out-of-state provider. Payment will be made directly to the out-of-state provider. (Eff. 2/1/2010, Register 193)


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Authority: AS 47.05.010 AS 47.07.030 AS 47.07.045 7 AAC 130.225. Provider disenrollment and decertification. (a) The department may disenroll and decertify a provider of a home and community-based waiver service under 7 AAC 130.200 - 7 AAC 130.319 (1) if the department determines that the provider is no longer qualified for certification as required under 7 AAC 130.220 for a home and community-based waiver service; (2) for grounds and under procedures set out in 7 AAC 105.400 - 7 AAC 105.490; or (3) if the provider fails to meet applicable requirements in the department’s Home and Community-Based Waiver Services Certification Application Packet adopted by reference in 7 AAC 160.900. (b) Providers who are disenrolled or decertified by the department under this section may appeal that decision under 7 AAC 105.460. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.045 7 AAC 130.230. Screening, assessment, plan of care, and level-of-care determination. (a) An applicant for home and community-based waiver services under 7 AAC 130.200 - 7 AAC 130.319 must obtain an initial, informal screening for use by the department to determine whether an assessment is warranted under (b) of this section. The department will offer the applicant a choice of care coordination agency providers. The applicant must obtain the screening from one of those providers. A care coordinator shall perform the screening. (b) If warranted by the screening under (a) of this section and supportive diagnostic documentation, and to determine if the applicant meets the level of care required under 7 AAC 130.205(d)(2), the department will authorize the care coordinator to prepare a complete assessment of the applicant’s physical, emotional, and cognitive functioning and need for care and services. If the assessment is to determine if the applicant falls within the recipient category for (1) individuals with mental retardation and developmental disabilities, the

(A) department will make a level-of-care determination under 7 AAC 140.600(c) - (d); and (B) level-of-care determination must incorporate the results of the Inventory for Client and Agency Planning (ICAP), adopted by reference in 7 AAC 160.900, that is administered under 7 AAC 140.600(c) - (d); or

(2) adults with physical disabilities or older adults, the (A) department will determine whether the applicant requires skilled care under 7 AAC 140.515 or intermediate care under 7 AAC 140.510; and (B) level of care determination under (A) of this paragraph must incorporate the results of the department’s Consumer Assessment Tool (CAT), adopted by reference in 7 AAC 160.900.

(c) After the level of care is established, the care coordinator shall (1) prepare, in writing, a plan of care addressing

(A) the comprehensive needs of the recipient;


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(B) the availability of enrolled providers; (C) the types of services that have been agreed to by specific enrolled providers; (D) family and community supports; and (E) the number of units, frequency, projected duration, and projected cost of each home and community-based waiver service;

(2) include in the plan of care an analysis of whether the type, amount, duration, and scope of services in the plan of care are consistent with the findings of the assessment in (b) of this section and with any other treatment plan for the recipient; (3) make a recommendation whether the services in the plan of care meet the identified needs of the recipient; (4) support the plan of care with appropriate and contemporaneous documentation that

(A) relates to each medical condition that places the recipient into a recipient category listed in 7 AAC 130.205(d)(1); and (B) describes, supports, or justifies the recipient’s request and need for home and community-based waiver services; and

(5) present the plan of care to the department for consideration and approval, and for consideration and approval of the home and community-based waiver services requested in the plan of care. (d) If a plan of care is for a recipient who falls within the recipient category for children with complex medical conditions or for individuals with mental retardation and developmental disabilities, (1) the care coordinator shall convene a comprehensive planning team to participate in preparing the plan of care; (2) the comprehensive planning team must consist of the

(A) recipient; (B) recipient’s

(i) family members, including parents, siblings, and others similarly involved in providing general oversight of the recipient; or (ii) legal guardian, if any;

(C) care coordinator; and (D) enrolled providers that are expected to provide services;

(3) each individual who participates on the comprehensive planning team shall verify that participation by signature on the recipient’s plan of care; and (4) any disagreement among participants about outcomes or service levels, or any suggestion by a participant for an outcome or service level that differs from what is in the plan of care, must be documented and attached to the plan of care when that plan of care is submitted to the department for consideration and approval. (e) Before the submission of a plan of care to the department for consideration and approval, the recipient or recipient’s representative must indicate by signature that individual’s agreement with the plan of care. (f) The department will approve a plan of care if the department determines that each service listed on the plan of care (1) is of sufficient amount, duration, and scope to prevent institutionalization;


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(2) is supported by the documentation required in (c)(4) of this section; and (3) cannot be provided under 7 AAC 105 - 7 AAC 160, except as a home and community-based waiver service under 7 AAC 130.200 - 7 AAC 130.319. (g) A recipient’s need for home and community-based waiver services must be reviewed annually using the same criteria used to determine initial eligibility under 7 AAC 130.205. A new assessment must be prepared in accordance with (b) of this section, and the recipient’s plan of care must be changed accordingly, unless the department determines that an earlier review is necessary due to changing and significant events in the health and welfare of the recipient. The care coordinator shall submit in writing, for the department’s consideration and approval, any change to a recipient’s plan of care, shall document the need for changes to the plan of care, and shall relate those changes to findings in the current assessment. If a comprehensive planning team is required under (d) of this section, the team must participate in preparing, in accordance with that subsection, any subsequent changes to the plan of care. If the department determines that adequate documentation is not provided, the department may cap service levels at prior year levels, or reduce service levels to reflect the recipient’s historical usage. Before the submission of any change to a plan of care to the department for consideration and approval, the recipient or the recipient’s representative must indicate by signature that individual’s agreement with that change. The department will approve changes to a plan of care if the department determines that (1) the amount, scope, and duration of services to be provided will reasonably achieve the purposes of the plan of care, and are sufficient to prevent institutionalization; (2) each service to be provided is supported by documentation as required by (c)(4) of this section; and (3) the services to be provided are not otherwise covered under 7 AAC 105 - 7 AAC 160, except as a home and community-based waiver service under 7 AAC 130.200 - 7 AAC 130.319. (h) The plan of care required in (c) of this section must be completed no more than 60 days after completion of an initial assessment required in (b) of this section, or no more than 30 days after the completion of a new assessment required in (g) of this section, unless the care coordinator submits written documentation of unusual circumstances that would prevent timely completion of the plan of care. (i) Notwithstanding (a), (b), (c), or (g) of this section, the department may perform the screening, assessment, or plan-of-care development for an applicant or recipient itself. (j) Screenings, assessments, and plans of care under this section must be completed on a form or in a format approved by the department. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.045 7 AAC 130.235. Nursing oversight. (a) The department will require nursing oversight in the form and frequency required under (b) of this section if (1) in the course of receiving a home and community-based waiver service, a recipient is to perform self-care of a medical nature or receive care of a medical


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nature from an individual, regardless of whether the individual is a home and community-based waiver services provider or employed by that provider; (2) the individual to perform care under (1) of this subsection is not licensed under AS 08 in a health care profession in which the competent delivery of that form of care is a prerequisite for licensure; and (3) the recipient is within the recipient category for

(A) children with complex medical conditions; or (B) individuals with mental retardation and developmental disabilities, but would be eligible under the recipient category for children with complex medical conditions if the individual were under 22 years of age.

(b) Nursing oversight must (1) be provided by a registered nurse licensed under AS 08.68 who is

(A) a care coordinator enrolled under 7 AAC 130.240(a), and employed by a care coordination agency provider; (B) employed by a home and community-based waiver services provider, and who provides nursing oversight as a component of another Medicaid service; or (C) employed by a private health care provider, and who submits verification of nursing oversight through written reports of scope and frequency that are approved under 7 AAC 130.230 as part of the recipient’s plan of care; and

(2) include contacts between the registered nurse, the recipient, and any individual described in (a)(1) and (2) of this section, during which the registered nurse shall confirm that the care is being delivered in a manner that protects the health and safety of the recipient; the department will determine the number and frequency of required contacts, not to exceed one contact per month, and as appropriate to the medical condition of the recipient and the complexity of the care to be delivered. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.045 7 AAC 130.240. Care coordination services. (a) An employee of a care coordination agency rendering care coordination services must be separately enrolled under this subsection as a care coordinator with the department. Before an employee of a care coordination agency can provide care coordination services, the care coordination agency must (1) be certified and enrolled with the department in accordance with 7 AAC 130.220; (2) certify, in writing, to the department, that the employee

(A) meets the minimum requirements listed in the "Care Coordinator Provider Standards" text on pages 13 - 14 of the department’s Home and Community-Based Waiver Services Certification Application Packet, adopted by reference in 7 AAC 160.900; (B) is employed by the care coordination agency; and (C) meets the agency’s employment and certification standards to provide care coordination services; and

(3) provide documentation as listed for the employee in the "Required Attachments" text on pages 14 - 15 of the department’s Home and Community-Based


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Waiver Services Certification Application Packet, adopted by reference in 7 AAC 160.900. (b) The department will pay for the following services: (1) for an applicant, one screening per calendar year under 7 AAC 130.230(a), except that the department will pay for a second screening if the applicant was determined, based on the first screening, ineligible for home and community-based waiver services; (2) for an applicant or recipient, one initial assessment under 7 AAC 130.230(b) per calendar year; (3) for a recipient, one development of a plan of care per calendar year, if that plan of care is accompanied by the form required under 7 AAC 130.205(h) documenting the recipient’s choice of home and community-based waiver services; the plan of care must be developed in accordance with 7 AAC 130.230, except that the department will pay for a plan of care

(A) for which agreement of the recipient or the recipient’s representative was not obtained under 7 AAC 130.230(e), if the department would have approved the plan of care had agreement been obtained; or (B) that was developed in reliance on the form required under 7 AAC 130.205(h), but that the department cannot approve because home and community-based waiver services were subsequently determined not to be available under 7 AAC 130.205(b).

(c) The department will pay a care coordinator for ongoing care coordination services provided to each recipient, beginning with the first month that the recipient is enrolled under 7 AAC 130.205(e) and has a plan of care approved under 7 AAC 130.205(f)(1). Ongoing care coordination services include (1) routine monitoring and support; (2) review and revision of a plan of care under 7 AAC 130.230(g); (3) case terminations; (4) two contacts each month with the recipient, one of which must be face-to-face; however, the department will waive the monthly face-to-face requirement if the plan of care documents, to the department’s satisfaction, that the recipient lives in a rural community as defined in 7 AAC 130.300(c)(5)(B); if the department waives the monthly face-to-face requirement, the care coordinator must document a minimum of one face-to-face visit per calendar quarter with each recipient whom the care coordinator serves, to monitor service delivery; notwithstanding a waiver under this paragraph, if the purpose of a contact is to develop the annual plan of care for the recipient, that contact must be face-to-face; (5) evaluation of the need for specific home and community-based waiver services; (6) coordination of multiple services and providers; and (7) monitoring of the quality of care. (d) The department will pay a care coordinator for one new assessment under 7 AAC 130.230(g) during the 12-month period following the month that the recipient is enrolled under 7 AAC 130.205(e), and for no more than two new assessments during each subsequent 12-month period. (e) The department will not pay for care coordination services provided by the


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recipient, a member of the recipient’s immediate family, the recipient’s guardian, a holder of power of attorney for the recipient, or the recipient’s personal care assistant. (f) No more than seven days after a recipient’s admission to or subsequent discharge from a general acute care hospital, the recipient’s care coordinator shall notify the department of the date of the admission or discharge, to assist the department in determining the correct payment amount payable to providers of home and community-based waiver services to that recipient. (g) Notwithstanding (b) and (d) of this section, the department will pay for additional screenings, assessments, or plans of care that have received prior authorization. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.045 AS 47.07.030 7 AAC 130.245. Chore services. (a) The department will pay for chore services that (1) are approved under 7 AAC 130.230 as part of the recipient’s plan of care; (2) receive prior authorization; and (3) do not exceed

(A) 10 hours per week for recipients within the following recipient categories:

(i) adults with physical disabilities; (ii) older adults; or

(B) five hours per week for recipients within the following recipient categories:

(i) children with complex medical conditions; however, if a recipient in that recipient category has a documented history of respiratory illness, the department will pay for chore services not to exceed 10 hours per week; (ii) individuals with mental retardation and developmental disabilities.

(b) The department will consider the following services to be chore services: (1) regular cleaning within the residence used by the recipient; (2) performing heavy household chores, including

(A) washing floors, windows, and walls; (B) tacking down loose rugs and tiles; (C) moving heavy items of furniture; and (D) snow shoveling in order to provide safe access and egress;

(3) food preparation and shopping for recipients in the following recipient categories:

(A) adults with physical disabilities; (B) older adults;

(4) other services that the department determines necessary to maintain a clean, sanitary, and safe environment with respect to the residence used by the recipient. (c) The department will not authorize chore services if (1) the recipient or anyone else in the household is capable of performing


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or financially providing for them; (2) any other relative or caregiver of the recipient, or any community or volunteer agency or third-party payer is capable of or responsible for the provision of those services; or (3) the recipient’s residence is a rental property, and the department determines those services to be the responsibility of the landlord under the lease or applicable law. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.045 AS 47.07.030 7 AAC 130.250. Adult day services. (a) The department will pay for adult day services that (1) are provided to a recipient in one of the following recipient categories:

(A) adults with physical disabilities; (B) older adults;

(2) are approved under 7 AAC 130.230 as part of the recipient’s plan of care; (3) receive prior authorization; and (4) are provided to a recipient who does not experience a developmental disability. (b) The department will consider health, social, and related support services to be adult day services if (1) they are provided in a protective setting, other than a nursing facility, during any part of a day, but less than 24 hours per day; and (2) recipients attend those services on a planned basis during specified hours. (c) The department will not pay for adult day services that duplicate (1) services performed by personal care assistants under 7 AAC 125.010 - 7 AAC 125.199; or (2) other home and community-based waiver services. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.045 AS 47.07.030 7 AAC 130.255. Residential supported-living services. (a) The department will pay for residential supported-living services that (1) are provided to a recipient in one of the following recipient categories:

(A) adults with physical disabilities; however, the department will pay only if a recipient in that recipient category does not experience a developmental disability; (B) older adults;

(2) are approved under 7 AAC 130.230 as part of the recipient’s plan of care; (3) receive prior authorization; and (4) are provided in an assisted living home licensed under AS 47.32. (b) The department will consider services to be residential supported-living


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services if they (1) assist, in a residential setting, a recipient with the activities of daily living; and (2) are designed for a recipient who can no longer live alone and who does not need 24-hour care provided by a nursing facility, but who would be placed in a nursing facility for lack of alternate placements. (c) The department will not pay (1) for residential supported-living services that are provided the same day as the recipient receives

(A) personal care assistant services payable under 7 AAC 125.010 - 7 AAC 125.199; (B) chore services payable under 7 AAC 130.245; (C) meals services payable under 7 AAC 130.295, unless the meals are provided in a congregate setting other than an assisted living home licensed under AS 47.32; or (D) respite care services payable under 7 AAC 130.280; or

(2) under this section for (A) payment of the recipient’s room and board; (B) the cost of facility maintenance, upkeep, or improvement, except for actual costs for modifications or adaptations to a facility required to assure the health and safety of residents or to meet the life safety requirements of 13 AAC 50, 13 AAC 55, or an applicable municipal code; or (C) activities or supervision for which a source other than Medicaid makes payment; or

(3) for residential supported-living services that are subject to the restrictions in 7 AAC 130.310. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.045 AS 47.07.030 7 AAC 130.260. Day habilitation services. (a) The department will pay for day habilitation services that (1) are provided to a recipient in one of the following recipient categories:

(A) children with complex medical conditions; (B) adults with physical disabilities; however, the department will pay only if a recipient in that recipient category is also diagnosed as experiencing a developmental disability: (C) individuals with mental retardation or developmental disabilities;

(2) are approved under 7 AAC 130.230 as part of the recipient’s plan of care; and (3) receive prior authorization. (b) The department will consider habilitation services to be day habilitation services if they (1) take place in a nonresidential setting, separate from the home, assisted living home licensed under AS 47.32, or foster home licensed under AS 47.32 in which the recipient resides; for purposes of this paragraph, day habilitation services include


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transportation of the recipient between the home, assisted living home, or foster home where the recipient resides and the site where the services are provided; and (2) do not replace, enhance, or supplement educational services for which the recipient is eligible under 4 AAC 52. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.045 AS 47.07.030 7 AAC 130.265. Residential habilitation services. (a) The department will pay for residential habilitation services that (1) are provided to a recipient in one of the following recipient categories:

(A) children with complex medical conditions; (B) adults with physical disabilities; however, the department will pay only if a recipient in that recipient category is also diagnosed as experiencing a developmental disability; (C) individuals with mental retardation or developmental disabilities;

(2) are approved under 7 AAC 130.230 as part of the recipient’s plan of care; and (3) receive prior authorization. (b) Payment for residential habilitation services will be limited to the following habilitation services, and is subject to the following limitations: (1) family habilitation home services; the department will consider habilitation services to be family habilitation home services if they are provided to a recipient who spends more than 50 percent of the time in an assisted living home or foster home licensed under AS 47.32, and if the home has a paid primary caregiver in residence who is not a member of the recipient’s immediate family; payment under this paragraph is subject to the following limitations:

(A) the total number of individuals receiving care in the home, regardless of whether they receive home and community-based waiver services, may not exceed

(i) two, for a recipient in the recipient category of children with complex medical conditions; however, the total number may be exceeded to allow the placement of siblings with the same primary caregiver in residence; (ii) three, for a recipient in the recipient category of adults with physical disabilities; or (iii) three, for a recipient in the recipient category of individuals with mental retardation or developmental disabilities; however, the total number may be exceeded to allow the placement of siblings with the same primary caregiver in residence;

(B) the department will not make separate payment for (i) chore services under 7 AAC 130.245; (ii) transportation services under 7 AAC 130.290; or (iii) meals services under 7 AAC 130.295;

(2) shared-care services; the department will consider habilitation services to be shared-care services if they are provided to a recipient who spends more than 50


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percent of the time in the home of an unpaid primary caregiver and the remainder in an assisted living home or foster home licensed under AS 47.32; (3) supported-living services; the department will consider habilitation services to be supported-living services if they are provided to a recipient 18 years of age or older and in the recipient’s private residence, subject to the following limitations:

(A) the department will not pay for more than 18 hours per day of supported-living services, unless the department determines that the recipient is unable to benefit from other home and community-based waiver services; (B) other persons also may furnish direct care services after providing written assurance to the department that those services do not supplant services provided by informal community supports; for purposes of this subparagraph, "direct care services" includes

(i) personal care assistants under 7 AAC 125.010 - 7 AAC 125.199; (ii) chore services under 7 AAC 130.245; (iii) transportation services under 7 AAC 130.290; and (iv) meals services under 7 AAC 130.295;

(4) group-home habilitation services; the department will consider habilitation services to be group-home habilitation services if they are provided to a recipient 18 years of age or older living full-time in an assisted living home licensed under AS 47.32; (5) in-home support services; the department will consider habilitation services to be in-home support services if they are provided in the recipient’s private residence where an unpaid primary caregiver resides; if a recipient receives in-home support services, the department will not make separate payment for

(A) personal care assistants under 7 AAC 125.010 - 7 AAC 125.199; (B) chore services under 7 AAC 130.245; (C) transportation services under 7 AAC 130.290; or (D) meals services under 7 AAC 130.295. (Eff. 2/1/2010, Register 193)

Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 130.270. Supported-employment services. (a) The department will pay for supported-employment services that (1) are provided to a recipient in one of the following recipient categories:


(2) are approved under 7 AAC 130.230 as part of the recipient’s plan of care; if a recipient is under 22 years of age, the plan of care must document that the supported-employment services to be received do not duplicate or supplant educational services for which a recipient is eligible under 4 AAC 52; and


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(3) receive prior authorization. (b) The department will consider services to be supported-employment services if (1) they are provided at a work site in which individuals without disabilities are employed; (2) they include only the adaptations, supervision, and training required by individuals receiving home and community-based waiver services as a result of their disabilities; and (3) the recipient is unlikely to obtain competitive employment at or above the minimum wage and, because of the recipient’s disability, needs intensive ongoing support, including supervision and training, to perform in a work setting. (c) The department will not pay for (1) services otherwise available under a program paid for with money provided under 20 U.S.C. 1400 - 1482 (Individuals with Disabilities Education Act) or 29 U.S.C. 730 (Rehabilitation Act); (2) supervisory activities rendered as a normal part of the business; or (3) accommodations routinely provided to employees. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 130.275. Intensive active treatment services. (a) The department will pay for intensive active treatment services (1) that are provided to a recipient in one of the following recipient categories:


(2) that are approved under 7 AAC 130.230 as part of the recipient’s plan of care; (3) that receive prior authorization; and (4) for which the professional providing or supervising the services submits supporting documentation to the department that the recipient needs immediate intervention to decelerate a condition or behavior regression that, if left untreated, would place the recipient at risk of institutionalization. (b) The department will consider services to be intensive active treatment services if (1) the department determines them to provide specific treatment or therapy, in the form of time-limited interventions to address a family problem or a personal, social, behavioral, mental, or substance abuse disorder in order to maintain or improve effective functioning of the recipient; (2) each intervention requires the precision and knowledge possessed only by specifically trained professionals in specific disciplines, whose services are not covered under Medicaid or as habilitation services under 7 AAC 130.260 - 7 AAC 130.265; and


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(3) the treatment or therapy is designed and provided by a professional licensed under AS 08 with expertise specific to the diagnosed condition, or by a paraprofessional licensed under AS 08 if necessary and supervised by that professional. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 130.280. Respite care services. (a) The department will pay for respite care services that (1) are approved under 7 AAC 130.230 as part of the recipient’s plan of care; (2) receive prior authorization; and (3) do not exceed the maximum number of hours and days in (c) of this section. (b) The department will consider services to be respite care services if they provide alternative caregivers, regardless of whether the services are provided in the recipient’s home or at another location, to relieve (1) primary unpaid caregivers, including family members and court-appointed guardians; (2) providers of family habilitation home services under 7 AAC 130.265(b)(1), except as provided in (e)(4) of this section; or (3) foster parents licensed under AS 47.32. (c) The department will not pay for respite care services that exceed the following duration limits: (1) 520 hours of hourly respite care services per year, unless the lack of additional care or support would result in risk of institutionalization because

(A) the recipient has inadequate supports from unpaid caregivers; or (B) appropriate out-of-home daily respite care services are unavailable;

(2) 14 days of daily respite care services per year. (d) The department will pay under this section for respite care services subject to the following limitations: (1) the department will pay for room and board expenses incurred during the provision of respite care services only if the room and board are provided in

(A) a nursing facility; (B) a general acute care hospital; (C) an intermediate care facility for the mentally retarded (ICF/MR); (D) an assisted living home licensed under AS 47.32, and that home is not the recipient’s residence; or (E) a foster home licensed under AS 47.32, and that home is not the recipient’s residence;

(2) the department will not pay more than daily rate established in 7 AAC 145.520 for respite care services, whether provided singly or in combination, other than out-of-home daily respite care services; (3) the department will not pay for out-of-home daily respite care services


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at a rate in excess of the rate established for Medicaid providers under 7 AAC 105 - 7 AAC 160; (4) the department will not pay for respite care services to

(A) allow a primary caregiver to work; (B) relieve other paid providers of Medicaid services, except providers of family habilitation home services under 7 AAC 130.265(b)(1); or (C) provide oversight for additional minor children in the home; for purposes of this subparagraph, "additional minor children" means unemancipated individuals under 18 years of age other than recipients;

(5) the department will pay for respite care services provided at the same time as personal care assistants under 7 AAC 125.010 - 7 AAC 125.199 or habilitation services provided under 7 AAC 130.260 - 7 AAC 130.265 only if the lack of additional care or support would result in risk of institutionalization because

(A) the recipient has inadequate supports from unpaid caregivers; or (B) appropriate out-of-home daily respite care services are unavailable;

(6) the department will not pay for hourly respite care services provided to recipients receiving residential supported-living services under 7 AAC 130.255. (e) The department will pay under this section for family-directed respite care services subject to the following additional limitations: (1) family-directed respite care services will be paid only for a recipient in one of the following recipient categories:

(A) children with complex medical conditions; (B) individuals with mental retardation or developmental disabilities;

(2) family-directed respite care services must be provided through a home and community-based waiver services provider that is certified and enrolled under 7 AAC 130.220 to provide respite care services; prior authorization will not be given unless the department has on file a current letter of agreement, in which the home and community-based waiver services provider acknowledges responsibility to

(A) comply with the requirements of AS 47.05.017 with respect to an individual retained and directed by a family to provide respite care services under this subsection; and (B) ensure that the retention and direction of an individual by a family to provide respite care services under this subsection is in accordance with municipal, state, and federal law

(i) applicable to employment of that individual, including applicable provisions of 26 U.S.C. (Internal Revenue Code); or (ii) to protect the health and safety of the recipient;

(3) out-of-home daily respite care services may not be provided as family-directed respite care services; (4) family-directed respite care services may not be provided to relieve providers of family habilitation home services under 7 AAC 130.265(b)(1); (5) primary unpaid caregivers of a recipient receiving family-directed respite care services may not provide the service for other recipients of family-directed


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respite care services; (6) a primary unpaid caregiver

(A) may identify and train individuals who meet the minimum requirements listed in the "Respite Services Provider Standards" text on page 26 of the department’s Home and Community-Based Waiver Services Certification Application Packet, adopted by reference in 7 AAC 160.900; (B) may complete and sign timesheets for individuals providing family-directed respite care services; and (C) shall provide, to the home and community-based waiver services provider that has received prior authorization for the family-directed respite care services, written assurance that the primary unpaid caregiver understands the additional risk that the primary unpaid caregiver assumes in the provision of family-directed respite care services;

(7) individuals providing family-directed respite care services shall be paid directly by the home and community-based waiver services provider that received prior authorization for those services. (f) In this section, (1) "daily respite care services" means respite care services no less than 12 and no more than 24 hours in duration; (2) "family-directed respite care services" means respite care services provided by an individual whom

(A) the family of the recipient retains; and (B) a home and community-based waiver services provider pays;

(3) "out-of-home daily respite care services" means daily respite care services provided in

(A) a nursing facility; (B) a general acute care hospital; (C) an intermediate care facility for the mentally retarded or persons with related conditions (ICF/MR); (D) an assisted living home licensed under AS 47.32; or (E) a foster home licensed under AS 47.32. (Eff. 2/1/2010, Register 193)

Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 130.285. Specialized private-duty nursing services. (a) The department will pay for specialized private-duty nursing services that (1) are provided to a recipient

(A) in one of the following recipient categories: (i) adults with physical disabilities; (ii) individuals with mental retardation or developmental disabilities; however, the department will pay only if a recipient in that recipient category is 21 years of age or older; (iii) older adults; and

(B) who meets the eligibility requirements that apply to a Medicaid recipient under 21 years of age under 7 AAC 110.525(a);

(2) are approved under 7 AAC 130.230 as part of the recipient’s plan of


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care; and (3) receive prior authorization. (b) The department will consider services to be specialized private-duty nursing services if they (1) provide individual and continuous care by individuals licensed under AS 08.68 other than certified nurse aides; and (2) are tailored to the specific needs of a particular individual. (c) The department will not pay under this section for temporary or intermittent services, and will not pay under this section for services that fail to satisfy the requirements and limitations of 7 AAC 110.520 - 7 AAC 110.539, except that the cost cap limitations in 7 AAC 145.250 do not apply. (d) To provide services under this section, an employee subject to 7 AAC 110.520(b) must be enrolled separately under that subsection. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 130.290. Transportation services. (a) The department will pay for transportation services that (1) are approved under 7 AAC 130.230 as part of the recipient’s plan of care; and (2) receive prior authorization. (b) The department will consider services to be transportation services if they enable a recipient, and any necessary escort that receives prior authorization under (a)(2) of this section, to gain access to home and community-based waiver services or other community services and resources. (c) The department will not pay under this section for (1) medical transportation services payable under 7 AAC 120.400 - 7 AAC 120.490; or (2) transportation paid under 7 AAC 130.265. (d) In this section, "escort" means an individual who accompanies a recipient to or from a service using a transportation provider enrolled under 7 AAC 130.220. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 130.295. Meals services. (a) The department will pay for meals services that (1) are provided to a recipient 18 years of age or older; (2) are approved under 7 AAC 130.230 as part of the recipient’s plan of care; and (3) receive prior authorization. (b) The department will pay under this section for meals services subject to the following limitations: (1) meals must be provided in the recipient’s home, or in a congregate setting other than an assisted living home licensed under AS 47.32; (2) meals must be provided as described in 42 U.S.C. 3030g. (Eff. 2/1/2010, Register 193)


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Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 130.300. Environmental modification services. (a) The department will pay for environmental modification services that (1) are approved under 7 AAC 130.230 as part of the recipient’s plan of care; and (2) receive prior authorization. (b) The department will consider services to be environmental modification services if they make physical adaptations to the recipient’s home, as identified in the recipient’s plan of care, and are necessary to ensure the health, welfare, and safety of the recipient. (c) To pursue payment from the department under this section, a home and community-based waiver services provider must comply with the following requirements: (1) before an environmental modification service is approved as part of the recipient’s plan of care, the home and community-based waiver services provider that is to deliver the service must demonstrate to the department that the requirements of AS 08.18 for contractor registration and bonding have been met; (2) upon completion of an environmental modification service, the home and community-based waiver services provider shall verify compliance with applicable provisions of 13 AAC 50, 13 AAC 55, and applicable municipal building codes; (3) the home and community-based waiver services provider with prior authorization for the environmental modification service must complete the service or subcontract with a contractor registered and bonded under AS 08.18; (4) for environmental modification services expected to exceed $1,000, cost estimates from three home and community-based waiver services providers must be solicited and, if obtained, appended to the plan of care; (5) the cost of all environmental modification services for a recipient, including the cost of labor and the cost of building materials, parts, supplies, permits, demolition, and other goods that are necessary to accomplish the modifications in the recipient’s home and that remain with the recipient, may not exceed a total of $10,000 in a continuous 36-month period, beginning with the month the recipient is enrolled under 7 AAC 130.205(e), and may not exceed a total of $10,000 in each subsequent continuous 36-month period that the recipient remains enrolled; however, within any of those periods, the total for environmental modification services may exceed $10,000 if the excess expenditure

(A) is for the repair or replacement of a previous environmental modification, does not exceed $500 per year of the remaining 36-month period, and is approved by the department before the expenditure is made; or (B) results solely from the cost of freight to deliver materials and supplies to a rural community; in this subparagraph, "rural community" means a municipality or unincorporated community that is a social unit, that has a residential population of no less than 25 and no more than

(i) 10,000, and that is not connected by road or rail to Anchorage or Fairbanks; for purposes of this sub-subparagraph, a connection by road or rail does not include a connection by the Alaska


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marine highway system or by an international highway; or (ii) 1,600, and that is connected by road or rail to Anchorage or Fairbanks and at least 50 miles outside of Anchorage or 25 miles outside of Fairbanks; for purposes of this sub-subparagraph, a connection by road or rail does not include a connection by the Alaska marine highway system or by an international highway;

(6) in addition to paying for the actual environmental modification services, the department will pay the home and community-based waiver services provider an administrative fee under 7 AAC 145.520(e), if the provider

(A) is certified and enrolled under 7 AAC 130.220(b)(1)(J); and (B) acts as an organized health care delivery system under 42 C.F.R. 447.10 for the purpose of overseeing the purchase of an environmental modification for a recipient;

(7) once the home and community-based waiver services provider that received the prior authorization has been paid in full, the environmental modification will be considered complete and the provider shall be financially responsible for any additional work necessary to complete the modification. (d) The department will not pay under this section for (1) modifications that increase the square footage of an existing residence, are part of a larger renovation to an existing residence, or are included in construction of a new residence; (2) general utility adaptations, modifications, or improvements to the existing residence; for purposes of this paragraph, general utility adaptations

(A) include routine maintenance or improvements, including flooring and floor coverings, bathroom furnishings, carpeting, roof repair, central air conditioning, heating system or sewer system replacement, appliances, cabinets, and shelves; and (B) do not include improvements made to substantially reduce the risk of serious injury or illness to the recipient if another practical modification is not available to reduce that risk;

(3) adaptations, modifications, or improvements to the exterior of the dwelling, including outbuildings, yards, driveways, and fences, except for adaptations, modifications, or improvements to doors, exterior stairs, and porches necessary for egress for the recipient; (4) duplicate accessibility modifications to the same residence; (5) elevator installation, repair, or maintenance; or (6) installation of privately purchased specialized medical equipment that would not be paid under 7 AAC 130.305. (e) The department will pay for an environmental modification service under this section only upon completion of the environmental modification and upon compliance with (g) of this section, except that the department will issue prior authorization for 25 percent or less of the accepted cost estimate for materials required for an environmental modification service plus 25 percent or less of the cost for any specialized medical equipment, material, and supplies not locally available, if the department determines that those materials and the specialized medical equipment, material, and supplies are essential to the environmental modification service. The home and community-based


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waiver services provider shall repay the department for any charges paid on this prior authorization if the environmental modification is completed more than 90 days after the first date of billing. (f) Home and community-based waiver services providers shall purchase and install all required material, supplies, and equipment required for the environmental modification service, except for those supplies and equipment provided as specialized medical equipment and supplies under 7 AAC 130.305. (g) The department will make final payment under this section for an environmental modification service only upon submission by the (1) home and community-based waiver services provider to the department of a photograph of the completed environmental modification and a copy of a written final inspection by the municipality concurring that the project is complete and meets applicable codes; or (2) recipient or recipient’s representative to the department of written verification that the project is complete and a photograph of the completed environmental modification, if the recipient’s home is not within a municipality that conducts inspections. (h) The state is not responsible for removal of any modification if the recipient ceases to reside at a residence. (i) Environmental modifications will not be authorized for waiver recipients who reside in an assisted living home or foster home licensed under AS 47.32, unless the recipient residing in the assisted living home or foster home is receiving family habilitation home services under 7 AAC 130.265(b)(1). (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 130.305. Specialized medical equipment and supplies. (a) The department will pay for specialized medical equipment and supplies (1) that are approved under 7 AAC 130.230 as part of the recipient’s plan of care; (2) that receive prior authorization; and (3) for which the department receives written supportive contemporaneous documentation from a licensed physician, occupational therapist, physical therapist, speech therapist or pathologist, or physiatrist that the specific item requested is appropriate for the recipient, consistent with the plan of care, and necessary to avoid placing the recipient at risk of institutionalization. (b) The department will consider items to be specialized medical equipment and supplies if they are (1) devices, controls, or appliances that enable a recipient to increase the recipient’s ability to perform activities of daily living or to perceive, control, or communicate with the environment in which the recipient lives, or are ancillary supplies and equipment necessary for the proper functioning of those items; and (2) identified in the department’s Specialized Medical Equipment Fee Schedule, adopted by reference in 7 AAC 160.900. (c) The department will pay under this section subject to the following limitations: (1) the unit cost of equipment must be determined by including the cost of


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(A) training in the equipment’s proper use; and (B) routine fitting of and maintenance on the equipment necessary to meet applicable standards of manufacture, design, and installation;

(2) the cost of repair, modification, or adaptation of equipment may be paid as separate units of service, if the department determines that payment as separate units of service is cost-effective; (3) the department will not pay as a home and community-based waiver service the cost of any medical equipment or supplies that is payable under 7 AAC 120.200 - 7 AAC 120.299; (4) specialized medical equipment and supplies must be rented if the equipment is a personal emergency response system or if the department determines that renting the equipment is more cost-effective than purchasing it; (5) once purchased, specialized medical equipment and supplies become the property of the recipient; (6) specialized medical equipment may include a portable hydrotherapy tub device, but does not include items listed in (d)(1) of this section; (7) the department will not give prior authorization to replace specialized medical equipment before the end of that item’s expected useful life, unless the department determines that replacing rather than repairing that item is more cost-effective. (d) The department will not pay under this section for (1) hot tubs, spas, saunas, or permanently installed hydrotherapy devices; (2) developmental toys; (3) personal computers, other computer hardware, peripherals, computer software, personal data assistants (PDAs), or cellular telephones; (4) outdoor playground equipment, scissors lifts, bicycles, other pedal-driven devices, or exercise equipment; (5) lights or other devices used to treat seasonal affective disorder; (6) vacuum cleaners or household appliances; (7) devices that receive, record, or play audio or video in any medium, including televisions, compact disc players, MP3 players, videocassette players, and DVD players; (8) micro cars; or (9) adaptive clothing. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 130.310. Restrictions on residential supported-living services payment. (a) Unless waived in writing by the department under (b) of this section, the department will not pay for residential supported-living services provided under 7 AAC 130.255 to a recipient if that recipient’s approved plan of care was prepared by a care coordination agency provider that has a close familial or business relationship with the residential supported-living services provider. (b) The limitation on payment of certain residential supported-living services providers under (a) of this section may be waived by the department for the benefit of the recipient, subject to any conditions that the department may impose, based on one of the following considerations:


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(1) another care coordination agency provider is not reasonably available to serve the recipient; (2) the person rendering the care coordination service is not subject to supervision or control by the owner, administrator, or staff of the residential supported-living services provider and does not have a close familial or business relationship with the residential supported-living services provider or its owner or administrator. (c) In this section, (1) "close business relationship" means

(A) having a 15 percent or greater ownership, partnership, or equity interest in the other provider or its owner; or (B) having a 15 percent or greater ownership, partnership, or equity interest in any other business or commercial activity in which the other provider or its owner or administrator also has a 15 percent or greater ownership, partnership, or equity interest;

(2) "close familial relationship" includes the person’s spouse; a parent, sibling, or child of the person; and the spouse of the person’s parent, sibling, or child; (3) "owner" means a person having a 15 percent or greater ownership, partnership, or equity interest. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 130.319. Definitions. In 7 AAC 130.200 - 7 AAC 130.319, (1) "care coordination" means those services necessary to promote overall maintenance of the recipient’s physical survival, personal growth, and community participation; "care coordination" includes coordinating assessment and treatment services, facilitating access to appropriate and necessary services, assessing recipient skill level, providing treatment and crisis assistance planning, providing linkage between the recipient’s needs and services, coordinating the training of the recipient in the use of basic community resources, monitoring the overall provision of service and the recipient’s progress, providing social support, promoting treatment or community adjustment, providing advocacy to ensure that services are appropriate to the recipient’s needs, and providing outreach services necessary to assist the recipient in obtaining benefits to which the recipient is entitled; (2) "care coordination agency provider" means a provider that the department has enrolled under 7 AAC 130.220 to provide care coordination services under 7 AAC 130.240; (3) "habilitation services" means services that help recipients acquire, retain, or improve skills related to activities of daily living and self-help, social, and adaptive skills necessary to enable the recipient to reside in a noninstitutional setting that is provided in a recipient’s home, a shared-care environment, an assisted living home licensed under AS 47.32, or a foster home licensed under AS 47.32; (4) "immediate family" includes the parents or minor siblings of a recipient under 18 years of age and the spouse of a recipient; (5) "recipient category" means a category listed in 7 AAC 130.205(d)(1); (6) "residential supported-living services provider" means a provider that the department has enrolled under 7 AAC 130.220 to provide residential supported-living services under 7 AAC 130.255. (Eff. 2/1/2010, Register 193)


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Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 Department Note Regarding New Chapter 135: The Department of Health and Social Services, Division of Behavioral Health is currently working on integrated behavioral health regulations that will, in part, replace the community mental health clinic and substance abuse rehabilitation regulations currently remaining in 7 AAC 43 (see the end of this document). These new integrated behavioral health regulations will be placed in a new Chapter 135 at this location.


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Chapter 140. Medicaid Coverage; Facility and Facility-Based Services Article 1. Ambulatory Surgical Center Services (7 AAC 140.100. - 7 AAC 140.110) 2. Health Clinic Services; Federally Qualified Health Centers and Rural Health Clinics

(7 AAC 140.200 - 7 AAC 140.229) 3. Hospice Care Services (7 AAC 140.270 - 7 AAC 140.289) 4. Hospital Services (7 AAC 140.300 - 7 AAC 140.325) 5. Inpatient Psychiatric Hospital Services (7 AAC 140.350 - 7 AAC 140.365) 6. Residential Psychiatric Treatment Center (RPTC) Services (7 AAC 140.400 - 7 AAC

140.415) 7. Nursing Facility Services: SNF and ICF (7 AAC 140.500 - 7 AAC 140.595) 8. Intermediate Care Facility for the Mentally Retarded Services (7 AAC 140.600 -

7 AAC 140.640)

Article 1. Ambulatory Surgical Center Services. Section 100. Ambulatory surgical center enrollment requirements 105. Ambulatory surgical center services 110. Ambulatory surgical center reports 7 AAC 140.100. Ambulatory surgical center enrollment requirements. To be eligible for payment under 7 AAC 105 - 7 AAC 160 for ambulatory surgical center services, an ambulatory surgical center must (1) be enrolled in the Medicaid program under 7 AAC 105.210; (2) have a system to transfer recipients requiring emergency admittance or overnight care to a licensed, Medicaid-enrolled facility following any surgical procedure performed at the ambulatory surgical center; (3) have a department-approved utilization review plan under 7 AAC 160.140; and (4) except for ambulatory surgical centers operated by a tribal health program under 7 AAC 155.010, comply with the requirements of 7 AAC 150. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 140.105. Ambulatory surgical center services. (a) To be covered under 7 AAC 105 - 7 AAC 160, ambulatory surgical center services must be (1) preventative, diagnostic, therapeutic, rehabilitative, or palliative; (2) directly related to a surgical procedure provided to an outpatient by or under the direction of a physician or dentist; (3) provided in an ambulatory surgical center; and (4) listed in the Ambulatory Surgical Centers (ACS) Approved HCPCS Codes and Payment Rates, adopted by reference in 7 AAC 160.900. (b) The department will pay for use of the ambulatory surgical center to perform dental services covered by the department under 7 AAC 110.140 - 7 AAC 110.160, if use of the center is medically necessary. (c) An ambulatory surgical center may not provide overnight services.


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(d) An ambulatory surgical center must submit a claim to the department for services provided by the ambulatory surgical center separately from submitting a claim to the department for the services of physicians, anesthesiologists, radiologists, and dentists. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 140.110. Ambulatory surgical center reports. The department may request a copy of a full operative report, an interpretation of any film, or a pathologist’s report on tissue that is removed. When a procedure requires an operative or pathologist’s report or particular explanation or interpretation before payment, payment to the ambulatory surgical center is subject to receipt of the report, explanation, or interpretation for evaluation by the department. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040

Article 2. Health Clinic Services; Federally Qualified Health Centers and Rural Health Clinics.

Section 200. Health clinic enrollment and reporting 205. Federally qualified health centers 210. Rural health clinics 215. Health clinic services and payment conditions 220. Health clinic services provided off-site 229. Definitions 7 AAC 140.200. Health clinic enrollment and reporting. (a) The department will pay a health clinic for services provided to a recipient if the health clinic (1) meets the requirements of 42 C.F.R. 405.2400 - 405.2472, adopted by reference in 7 AAC 160.900; (2) is a federally qualified health center that meets the requirements of 7 AAC 140.205 or a rural health clinic that meets the requirements of 7 AAC 140.210; (3) is enrolled as a Medicare provider; (4) is enrolled as a federally qualified health center or rural health clinic in accordance with 7 AAC 105.210; (5) is not enrolled as another type of Medicaid provider of primary care or ambulatory services provided by the health clinic; (6) employs staff who meet the individual provider enrollment requirements for each service that the clinic provides if enrollment is required for that type of provider under 7 AAC 105 - 7 AAC 160; and (7) is enrolled as follows if the health clinic is providing those services:

(A) as a dental provider under 7 AAC 110.140; (B) as a dispensing pharmacy provider under 7 AAC 120.100; (C) as a nurse midwife under 7 AAC 110.100 or direct-entry midwife under 7 AAC 110.180, if providing professional services associated with labor and delivery.

(b) If a health clinic operates in more than one site in the state, each site must enroll separately and meet the requirements of this section.


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(c) For each site where it operates, a health clinic shall maintain sufficient financial records and statistical data to allow the department to identify and verify the costs and charges associated with providing services at each site. (d) On or before the last day of the fifth month after the close of its fiscal year, a health clinic shall file an annual year-end report, even if the clinic did not provide medical services to recipients during that fiscal year. The annual year-end report must contain the items listed in the definition of "year-end report" in 7 AAC 150.990, except that (1) Medicare home office cost statements are not required; (2) the required reconciliation of the post-audit working trial balance must be to the Medicare cost report worksheets A, A-1, and A-2; reconciliation may not be made to the Medicare cost report worksheets A-8, C, and G series; (3) the report must also include a worksheet detailing the total number of visits for the clinic’s fiscal year; the worksheet must include visits for dental and other ambulatory services; and (4) rural health clinics may provide reviewed financial statements meeting the requirements of 7 AAC 150.190(j)(3)(A) and (B) instead of audited financial statements. (e) If no change in the scope of services occurred during the health clinic fiscal year, and the health clinic does not intend to request a change, the health clinic shall submit to the department, on or before the last day of the fifth of the month after the close of that fiscal year, a written statement indicating that no change in the scope of services occurred or is being requested. (f) If a change in scope of services occurred during the health clinic fiscal year, the health clinic shall submit to the department the additional reports listed in this subsection. The data contained in these reports will be used to evaluate the change in scope of service request made under 7 AAC 145.700(f), to adjust the health clinic payment rates in accordance with that subsection, and to ensure, in accordance with 7 AAC 145.700(c)(4), that the prospective payment rate does not exceed upper payment limits. The reports must be submitted on or before the last day of the fifth month after the close of the health clinic fiscal year during which the change in the scope of services occurred, and on or before the last day of the fifth month after 12 continuous months of operation with the change. The reports must include the following: (1) a worksheet detailing the total number by which visits increased or decreased for the clinic’s fiscal year due to the change in the scope of services; (2) a narrative report that

(A) identifies the date the change in the scope of services occurred; and (B) describes the type of change in the scope of services;

(3) a spreadsheet that details the costs that are associated with the change in the scope of services and reported on the Medicare cost report; the spreadsheet must

(A) identify the working trial balance, account numbers, and cost centers; and (B) list all expense amounts associated with the change in the scope of services.

(g) If the facility receives an extension for filing the Medicare cost report from


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the Medicare intermediary, the facility must forward a copy of the intermediary’s letter that grants the extension to the facility to the department. The department will then grant an extension for the year-end report and the change-in-scope report to coincide with the due date given by the Medicare intermediary. Otherwise, for good cause shown to the department’s satisfaction, the department will grant a 30-day extension of the due date for submitting the information required under (d) - (f) of this section. In order to receive an extension from the department, a health clinic must submit to the department an extension request in writing before the due date. For purposes of this subsection, "good cause" (1) means circumstances beyond the control of the health clinic that cause the reporting due date to be missed by several days; and (2) includes natural disasters, hazardous weather, illness of the individual making the request, or specific medical emergencies that preclude timely submission. (h) The department will withhold 20 percent of the payment due to a health clinic if the clinic fails to submit complete information as required in (d) - (f) of this section. The department will restore, without interest, a payment withheld under this subsection, if the health clinic submits complete information as required in (d) - (f) of this section. (i) The department may conduct audits, perform special analysis, and review the records of a health clinic to verify compliance with Medicare and Medicaid laws, audit claims for payment submitted or paid, and make adjustments based on audits to a health clinic’s payment rate. A health clinic shall provide to the department financial and all other information regarding Medicaid claims for services provided to eligible recipients, shall provide Medicare cost reports upon request, and shall provide access to all facilities and records. (j) A health clinic may terminate its agreement to participate as a rural health clinic or a federally qualified health center by submitting a written notice to the department and identifying a termination date not less than 30 days after submitting the notice of termination. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.074 AS 47.07.030 AS 47.07.073 7 AAC 140.205. Federally qualified health centers. (a) To qualify as a federally qualified health center under 7 AAC 140.200 and this section and for payment under 7 AAC 145.700, a provider must meet at least one of the following eligibility requirements for the entire period for which Medicaid services are rendered: (1) a provider is receiving a grant under 42 U.S.C. 254b; (2) a provider is receiving money from a grant under (1) of this subsection under a contract with the grant recipient, and the provider also meets the requirements to receive that type of grant; (3) a provider is determined by the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS), to meet the requirements for receiving a grant under (1) of this subsection; (4) a provider is a tribal health program. (b) In addition to the requirements of 7 AAC 140.200, to enroll with the department, a federally qualified health center must (1) participate as a federally qualified health center in accordance with


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this section and 7 AAC 145.700, 42 C.F.R. 405.2430 - 405.2452, and 42 C.F.R. Part 491, adopted by reference in 7 AAC 160.900; and (2) provide the department with a letter from CMS, certifying the entity as a federally qualified health center provider, and must provide a copy of its grant notice; however, a tribal health program is exempt from providing documentation of certification. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.074 AS 47.07.030 AS 47.07.073 7 AAC 140.210. Rural health clinics. To qualify as a rural health clinic under 7 AAC 140.200 and this section and for payment under 7 AAC 145.700, a provider must be an entity that the department has certified under 42 C.F.R. Part 491 as being in compliance with 42 C.F.R. 405.2400 - 405.2417, adopted by reference in 7 AAC 160.900. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.074 AS 47.07.030 AS 47.07.073 7 AAC 140.215. Health clinic services and payment conditions. (a) The department will pay a health clinic for providing services under (b) - (e) of this section rendered to a patient of the clinic by an employee or a contract worker of the clinic. Except as otherwise provided in this section, the department will pay a provider for services under this section in accordance with the payment rate established in 7 AAC 145.700. (b) The department will pay for primary care services provided by a physician, a physician assistant, or an advanced nurse practitioner acting within the scope of that individual’s license to practice. The department will not pay for services that the department determines to be incidental to primary care services, including laboratory services, x-ray services, and supplies. (c) The department will pay for ambulatory services under 7 AAC 105 - 7 AAC 160, including (1) vision services under 7 AAC 110.705; (2) speech-language pathology services under 7 AAC 115.410; (3) hearing services under 7 AAC 115.520 and 7 AAC 115.530; (4) EPSDT screening and EPSDT services under 7 AAC 110.205 and 7 AAC 110.210; (5) podiatry services under 7 AAC 110.505; (6) nutrition services under 7 AAC 110.275 and 7 AAC 110.280; (7) private-duty nursing services under 7 AAC 110.525; (8) hospice services under 7 AAC 140.275 and 7 AAC 140.280; (9) family planning services under 7 AAC 110.230; (10) physical therapy services under 7 AAC 115.310; (11) occupational therapy services under 7 AAC 115.110; (12) chiropractic services under 7 AAC 110.120; and (13) nonprimary care services that are provided in a hospital by a rural health clinic physician, physician assistant, or advanced nurse practitioner acting within the scope of that individual’s license to practice.


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(d) The department will separately pay a health clinic for dental services covered under 7 AAC 110.145 - 7 AAC 110.160 provided by a dentist who is enrolled separately under 7 AAC 110.140. (e) The department will pay the established encounter rate to a health clinic for the behavioral health services identified in Table I-1. Procedure Codes: Mental Health Services of the Federally Qualified Health Center / Rural Health Clinic Services section of the Alaska Provider Billing Manual, adopted by reference in 7 AAC 160.900, if those services are provided to a recipient by a psychologist or a clinical social worker acting within the scope of that individual’s license to practice. Behavioral health services covered under this subsection include (1) psychiatric diagnostic interview procedures; (2) psychological testing and examination services; (3) individual psychotherapy; (4) group psychotherapy; in this paragraph, "group psychotherapy" has the meaning given in 7 AAC 43.1990; (5) family psychotherapy; and (6) health and behavior assessment and intervention services. (f) The department will separately pay a health clinic for labor and delivery services provided by a physician, a physician assistant, or an advanced nurse practitioner, including a nurse midwife, who has separately enrolled under 7 AAC 105 - 7 AAC 160. The department will pay a provider under this subsection in accordance with the relevant fee schedule established under 7 AAC 145.050. (g) The department will separately pay a health clinic for pharmacy services and for prescription drugs provided by the health clinic under 7 AAC 120.110 if the health clinic is enrolled as a dispensing provider in accordance with 7 AAC 120.100. The department will pay a provider under this subsection in accordance with the rates established in 7 AAC 145.400 and 7 AAC 145.410. (h) The department will not pay for (1) services or supplies that a health clinic routinely provides to individuals other than Medicaid-eligible recipients; (2) services or supplies that the health clinic routinely furnishes for free or without regard to the recipient’s ability to pay; or (3) services provided off-site of the health clinic, except as provided in 7 AAC 140.220. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.073 AS 47.07.030 AS 47.07.070 7 AAC 140.220. Health clinic services provided off-site. (a) The department will not pay a health clinic for services provided off-site unless (1) the health clinic patient is homebound as determined under (b) of this section and if all of the following conditions are met:

(A) the United States Department of Health and Human Services has determined that a shortage of home health agencies exists in the area; (B) services are furnished by a registered nurse, a licensed practical nurse, or a licensed vocational nurse who is employed by, or receives compensation for the services from, the clinic;


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(C) the services are furnished under a written plan of treatment that is

(i) established and reviewed at least every 60 days by a supervising physician of the health clinic or established by an advanced nurse practitioner or a physician assistant and reviewed at least every 60 days by a supervising physician; and (ii) signed by the advanced nurse practitioner, the physician assistant, or the supervising physician of the health clinic;

(D) the nursing care coverage is limited as specified in 42 C.F.R. 405.2416(b) and (c), adopted by reference in 7 AAC 160.900;

(2) a rural health clinic physician, acting within the scope of the physician’s license to practice, provides the services in a hospital or nursing facility; (3) a rural health clinic physician assistant or rural health clinic advanced nurse practitioner, acting within the scope of that individual’s license to practice, provides the services in a hospital; or (4) a federally qualified health center physician, physician assistant, or advanced nurse practitioner, acting within the scope of the individual’s license to practice, provides the services in a nursing facility. (b) A health clinic patient is homebound if, due to the individual’s medical or health condition, the individual is confined to the individual’s residence, or cannot leave the residence without considerable effort. The department will not disqualify an individual from being considered homebound for infrequent absences of short duration from the residence, including absences to attend religious services, or for absences from the residence in order to receive health care treatment, including participation in therapeutic or medical treatment as part of adult day services provided under 7 AAC 130.250 by a provider that is certified under 7 AAC 130.220. The department will not consider an individual to be homebound if the individual’s residence is a hospital or long-term care facility. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.073 AS 47.07.030 AS 47.07.070 7 AAC 140.229. Definitions. In 7 AAC 140.200 - 7 AAC 140.229, (1) "ambulatory services" means noninstitutional services that are payable under Medicaid and provided in accordance with this chapter; "ambulatory services" includes

(A) visual care; (B) speech; (C) hearing; (D) language; (E) EPSDT; (F) podiatry; (G) nutrition; (H) private duty nursing; (I) hospice care; (J) family planning; (K) physical therapy;


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(L) occupational therapy; (M) chiropractic; and (N) services that are not primary care services, that are provided by a physician, physician assistant, or advanced nurse practitioner, that are within the scope of that individual’s license to practice, and that are

(i) provided in or by a hospital; or (ii) laboratory or x-ray services only;

(2) "change in the scope of service" has the meaning given in 7 AAC 145.700(k); (3) "cost center" has the meaning given in 7 AAC 150.990; (4) "health clinic"

(A) means a federally qualified health center or a rural health clinic; (B) does not include a private or nonprofit medical practice or clinic that is not a federally qualified health center or rural health clinic;

(5) "visit" has the meaning given in 7 AAC 145.739. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040

Article 3. Hospice Care Services. Section 270. Hospice care provider enrollment 275. Hospice care services 280. Hospice care for individuals under 21 years of age 289. Definitions 7 AAC 140.270. Hospice care provider enrollment. (a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing hospice care services, the provider must (1) be enrolled in the Medicaid program under 7 AAC 105.210; (2) be a public or private organization that the department has certified as a hospice for the purposes of the Medicare program under 42 C.F.R. Part 418, adopted by reference in 7 AAC 160.900; and (3) provide hospice care services for periods of at least 210 days. (b) If the hospice care provider enrolled under (a) of this section employs individuals to provide professional or specialized services, those employees must individually meet any applicable state licensing requirements. (c) The department will not enroll a hospice care organization that is located out of state. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 140.275. Hospice care services. (a) Before the department will give prior authorization to and pay for hospice care services provided to a recipient in the recipient’s place of residence, the department must receive, no more than eight days after hospice care begins, (1) a certification, signed by the recipient’s attending physician and the


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medical director of the hospice, that the recipient’s medical prognosis is a life expectancy of six months or less if the illness runs its normal course; (2) a copy of the recipient’s care plan described in (d) of this section; and (3) an election statement, signed by the recipient or the recipient’s representative, that includes

(A) the name of the designated hospice; (B) an acknowledgment by the recipient, or the recipient’s representative, of an understanding of hospice care; (C) the effective date of the election; (D) an acknowledgment by the recipient, or the recipient’s representative, that for the duration of care, the recipient waives the recipient’s rights to hospice care by any other hospice unless arranged through the designated hospice, and waives the recipient’s rights to any other Medicaid-covered services related to the recipient’s terminal illness except for those provided by the designated hospice, an alternative hospice under arrangement with the designated hospice, or the recipient’s attending physician; (E) an acknowledgment of the recipient’s option to revoke the election of hospice care at any time; and (F) an acknowledgment of the recipient’s option to elect to change the designation of the hospice by submitting to both hospices a signed statement indicating the hospice from which care has been received, the newly designated hospice, and the date the change is effective; the recipient may only elect to change the designation of the hospice once in each election period as described in 42 C.F.R. 418.21 and 418.30, adopted by reference in 7 AAC 160.900.

(b) A recipient eligible for Medicare and Medicaid must make an election of a hospice, a designation of change of a hospice, or a revocation of a hospice simultaneously for both programs. (c) The following hospice care services are not paid separately from payments made for routine home care, continuous home care, inpatient respite care, or general inpatient care, as provided in 7 AAC 145.690: (1) preparation of a written plan of care that meets the requirements of (d) of this section; (2) a service rendered that is consistent with the written plan of care; (3) nursing care provided under the direction of a registered nurse; nursing care must be routinely provided by employees of the hospice; (4) medical social services rendered by a social worker under the direction of a physician; medical social services rendered by a social worker under the direction of a physician must be routinely provided by employees of the hospice; (5) physical, occupational, and speech therapy; (6) durable medical equipment, medical supplies, and biologicals and drugs that are used primarily for the relief of pain and symptom control of the terminal illness; (7) home health aide and homemaker services provided in the recipient’s home under the direction of a registered nurse; (8) counseling services provided to the recipient, family members, or caregiver for the purpose of enabling the family or caregiver to provide care, or aiding in


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adjustment to the recipient’s approaching death, and up to one year following the death of the recipient; counseling services described in this paragraph must be routinely provided by employees of the hospice. (d) A hospice care provider shall prepare a written plan of care that contains an initial plan of care expanded to a comprehensive plan of care. Before hospice service begins, a written initial plan of care must be completed by a registered nurse or physician in cooperation with at least one member of the interdisciplinary group. A comprehensive plan of care must be reviewed and updated at intervals, specified in the plan, by the hospice medical director or the recipient’s attending physician, and by the interdisciplinary group. The plan must include an assessment of the recipient’s needs and state in detail the scope and frequency of services needed to meet the recipient’s and family’s needs. (e) Nursing care, physician services, medical social services, and counseling are core hospice services and must be routinely provided by hospice employees. Physician services provided by the hospice must also meet the general medical needs of the recipient to the extent that the needs are not met by the recipient’s attending physician. (f) Continuous home care is to be provided only during a period of crisis in which a recipient requires constant care to reduce or manage acute medical symptoms as necessary to maintain a recipient at home. To be paid as continuous home care, a minimum of eight hours of care described in 42 C.F.R. 418.204, adopted by reference in 7 AAC 160.900, must be provided in each 24-hour period, and may be supplemented with homemaker and home health aide services; more than half of the continuous home care hours must be nursing care. If care less skilled than nursing services is required on a continuous basis to maintain the recipient at home, that care will be paid as routine home care. (g) The interdisciplinary group required by (d) of this section must include a doctor of medicine or osteopathy, a registered nurse, a social worker, and a counselor. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 140.280. Hospice care for individuals under 21 years of age. (a) Except as otherwise provided in this section, the department may enroll a hospice care provider and pay for hospice care services for a recipient under 21 years of age in the same manner as in 7 AAC 140.270 - 7 AAC 140.275 and 7 AAC 145.690. In addition to satisfying the requirements in 7 AAC 140.275, and no earlier than 12 months before hospice care services begin, the recipient must have had an EPSDT screening that meets the requirements in 7 AAC 110.205 for coverage. (b) In addition to the hospice care services eligible for payment under 7 AAC 140.275(c), a recipient under 21 years of age may receive private-duty nursing services rendered by or under the supervision of a registered nurse in a recipient’s home. The department will pay for those private-duty nursing services provided in a recipient’s home at the in-state rate established under 7 AAC 145.250. The department will not pay for out-of-state private-duty nursing services under this section. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040


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7 AAC 140.289. Definitions. In 7 AAC 140.200 - 7 AAC 140.289, (1) "continuous home care" means care provided during a period of crisis in which a recipient requires constant care to reduce or manage acute medical symptoms as necessary to maintain a recipient at home; (2) "general inpatient care" means care provided in a participating hospice inpatient unit or a participating general acute care hospital or nursing facility that meets the standards for staffing and recipient areas in 42 C.F.R. 418.98 or 42 C.F.R. 418.100, adopted by reference in 7 AAC 160.900, for procedures necessary for pain control or acute or chronic symptom management that cannot feasibly be provided in another setting; (3) "inpatient respite care" means a short-term admission of no more than five days for inpatient care in a facility that meets the standards in 42 C.F.R. 418.98(b), adopted by reference in 7 AAC 160.900, in order to provide relief to the caregiver; "inpatient respite care" does not include care provided to a recipient residing in a long-term care facility; (4) "interdisciplinary group" means a group of individuals designated by a hospice who provide or supervise the care and services offered by the hospice; (5) "routine home care" means any combination of the services listed in 7 AAC 140.275(c)(1) - (8) provided to a recipient electing hospice care that are not provided at the level and intensity of continuous home care. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040

Article 4. Hospital Services. Section 300. Hospital provider requirements 305. Admission to a hospital 310. Covered hospital services 315. Noncovered hospital services 320. Length of hospitalization 325. Billing for hospital services 7 AAC 140.300. Hospital provider requirements. (a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing hospital services, a provider must (1) be enrolled as a hospital in accordance with 7 AAC 105.210; (2) if located in the state,

(A) be licensed under AS 47.32, except for a hospital operated by a tribal health program; and (B) comply with the requirements of 7 AAC 150;

(3) if located out of state, meet all applicable licensing and accreditation requirements of the jurisdiction in which the hospital is located; (4) have a department-approved plan of utilization review; and (5) comply with all prior authorization requirements established under 7 AAC 105 - 7 AAC 160. (b) The provisions of 7 AAC 140.300 - 7 AAC 140.325 apply to all general acute care hospital services, including inpatient, outpatient, and emergency room services.


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Except as otherwise provided in 7 AAC 105 - 7 AAC 160, 7 AAC 140.300 - 7 AAC 140.325 do not apply to inpatient or outpatient psychiatric facility or residential psychiatric treatment center services. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.0303 AS 47.07.040 7 AAC 140.305. Admission to a hospital. The department will pay for inpatient hospital services only if the (1) recipient is admitted to the hospital by the written order of a physician or other licensed health care professional authorized to admit a patient to a hospital; (2) recipient requires a general acute care hospital level of care or meets the requirements for administrative-wait bed or swing-bed status; and (3) department gives prior authorization for admission as required under 7 AAC 105 - 7 AAC 160. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 140.310. Covered hospital services. (a) The department will pay for those hospital services for which a revenue code is listed in Section I of the Inpatient/Outpatient Hospital Services section of the Alaska Provider Billing Manual, adopted by reference in 7 AAC 160.900, and in the Covered Revenue Codes for Outpatient Hospitals and the Covered Revenue Codes for Inpatient Hospitals of the Indian Health Service (IHS)/Tribal Facility Services section of the Alaska Provider Billing Manual, adopted by reference in 7 AAC 160.900. Some revenue codes are for services that are limited based on recipient age, gender, and eligibility category as otherwise provided in AS 47.07, 7 AAC 100, or 7 AAC 105 - 7 AAC 160. (b) The department will pay for the standard daily hospital service, which includes room, linen service, meals, special diets, general nursing service, medical records and admitting service, use of ordinary hospital equipment and instruments, routine treatments, routine drugs, and routine supplies. (c) The department will pay for the central hospital service, which includes the cost of supplies and the cost of preparing, handling, and storing supplies. (d) The department will pay a hospital for drugs prescribed by the attending physician or other dispensing provider only if the drugs are administered to the recipient while the patient is receiving care in the hospital. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 140.315. Noncovered hospital services. (a) Except as otherwise provided in 7 AAC 105 - 7 AAC 160, the department will not pay for services (1) identified as noncovered services in 7 AAC 105.110; or (2) for which a revenue code is not listed as described in 7 AAC 140.310(a). (b) Except as otherwise provided in 7 AAC 105 - 7 AAC 160, the department will not pay a hospital for the following services and procedures: (1) a service that is not within the scope of the facility’s licensure, certification, or accreditation; (2) the following services, unless the department gives prior authorization specifically for the service:


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(A) the dispensing of antabuse; (B) methadone treatment, including the dispensing of methadone; (C) alcohol or drug detoxification or rehabilitation;

(3) tobacco cessation therapy and services; however, the department will pay for tobacco cessation products; (4) leaves of absence, including charges for holding a recipient’s room or bed, except as described under 7 AAC 140.585 when a recipient is in a hospital’s long-term care facility; (5) services and procedures that do not require hospital care, including

(A) outpatient special residence charges, rest cures, daily respite care under 7 AAC 130.280, adult day services, or day care for children; (B) room and board for individuals other than the patient, unless the department gives prior authorization specifically for the service; (C) admission solely for the purpose of medical and dental services, surgical procedures, or diagnostic testing that can be performed on an outpatient basis or in an ambulatory surgical center; however, the department will give prior authorization specifically for a service, procedure, or test if the recipient’s

(i) current medical condition or physical or mental disabilities are sufficiently severe that performing that service, procedure, or test on an outpatient basis or in an ambulatory surgical center would seriously endanger the recipient’s health; or (ii) recent medical history indicates that performing that service, procedure, or test on an outpatient basis or in an ambulatory surgical center would seriously endanger the recipient’s health;

(D) recipients who do not require or who no longer require acute inpatient care; however, the department will make a payment to the hospital for accommodation when no long-term care bed is available, if the department has approved the level of care appropriate for the recipient in situations involving a swing bed or administrative-wait bed; (E) custodial care related to court commitments; patients confined to a hospital under a court commitment for any reason will be covered for payment only to the extent medical necessity exists for inpatient hospital care; (F) recipients remaining beyond the length of stay authorized under 7 AAC 140.320; (G) recipients pending discharge when hospital care is no longer required; (H) days of care due to failure to promptly request or perform necessary diagnostic studies, medical-surgical procedures, or consultations; (I) disability examinations; (J) evaluative or periodic checkups, examinations, or immunizations that are connected with the participation in, enrollment in, attendance at, or accomplishment of a program or activity unrelated to the recipient’s physical or mental health or rehabilitation, except mammograms;

(6) organ transplants and related services, and dental implants, except that the department will make payment for organ transplants and requisite related medical


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care for (A) kidney and corneal transplants; prior authorization is not required; (B) skin and bone transplants for which the department has given prior authorization; (C) bone marrow transplants for which the department has given prior authorization; (D) liver transplants for which the department has given prior authorization, for persons with biliary atresia or other forms of end-stage liver disease; and (E) heart, lung, and heart-lung transplants for which the department has given prior authorization;

(7) weekend stays if admission was made on Friday or Saturday for surgery scheduled on Monday, except for an emergency or situation where the physical or mental condition of the patient necessitates extensive preoperative preparation or therapy; (8) professional fees in addition to those typically charged within specific cost centers, including osteopathic services, and except registered nurse anesthetist services; (9) separately identifiable preventive care services, clinic services, medical social services, and trauma team response activation charges; (10) nursing services and incremental nursing charges assessed in addition to accommodation charges, including private-duty nursing charges; (11) take-home drugs, oxygen, and supplies not otherwise classified; (12) home infusion therapy; (13) miscellaneous home dialysis charges; (14) educational services and supplies; (15) cardiac rehabilitation that exceeds the guidelines in the Medicare National Coverage Determinations Manual, Chapter 1, Part 1, Section 20.10 (Cardiac Rehabilitation Programs), adopted by reference in 7 AAC 160.900; (16) recreational therapy and medical rehabilitation day programs; (17) charges for services or items normally considered part of routine services and optional or special services not directly related to medical care, including

(A) private accommodation charges, unless medically necessary; (B) deluxe accommodation charges; (C) patient convenience items; and (D) routine service charges for accommodations that cannot be included in more specific revenue codes;

(18) personal services not normally associated with hospital care, including long-distance telephone calls, television rental, guest meals, and personal items. (c) The department will not pay for a service or inpatient stay for which prior authorization is denied, or is required but not obtained, including nonemergency out-of-state services for which prior authorization is not obtained under 7 AAC 105.130. (d) In this section, "cost center" has the meaning given in 7 AAC 150.990. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040


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7 AAC 140.320. Length of hospitalization. (a) Except as provided in (b) of this section, the department will not pay for more than three days of hospitalization for any single admission, except that, for a maternal and newborn hospital stay related to childbirth, the department will not pay for more than 48 hours of inpatient hospitalization for a single recipient following a normal vaginal delivery and no more than 96 hours of inpatient hospitalization for a single recipient following a cesarean delivery. (b) The department will not pay for coverage beyond the days or hours of hospitalization specified in (a) of this section unless the department has given prior authorization for those days or hours under 7 AAC 105.130. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 140.325. Billing for hospital services. The quality improvement organization (QIO) certification of necessity for hospital stays over three days or for stays for treatment or procedures on the Select Diagnoses and Procedures Pre-certification List, adopted by reference in 7 AAC 160.900, must appear on the invoice submitted by the hospital in order to receive payment. The department will pay only for days that are medically necessary and within the scope of Medicaid coverage. If a recipient refuses to leave the hospital at the end of a covered stay, the hospital may bill the recipient for days beyond the noncovered or noncertified portion of the hospital stay. Payment by the department for covered services is considered by the department to be payment in full for those covered services. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040

Article 5. Inpatient Psychiatric Hospital Services. Section 350. Inpatient psychiatric hospital provider requirements 355. Inpatient psychiatric hospital services 360. Inpatient psychiatric hospital admission 365. Inpatient psychiatric plan of care 7 AAC 140.350. Inpatient psychiatric hospital provider requirements. (a) To be eligible for payment under 7 AAC 43 and 7 AAC 105 - 7 AAC 160 for providing inpatient psychiatric hospital services, a provider must (1) be enrolled as an inpatient psychiatric hospital in accordance with 7 AAC 105.210; (2) if located in this state,

(A) be licensed under AS 47.32 and accredited by the Joint Commission; (B) comply with the requirements of 7 AAC 150;

(3) if located out of state, meet all applicable licensing and accreditation requirements of the jurisdiction in which the inpatient psychiatric hospital is located; and (4) meet the requirements of 7 AAC 140.350 - 7 AAC 140.365. (b) An inpatient psychiatric hospital provider shall record the results of each required screening, assessment, evaluation, and certification in a written report and


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include that report in the recipient’s medical record. (c) An inpatient psychiatric hospital provider shall provide an accounting for any funds accepted from a patient for safekeeping and shall make that accounting available for inspection by designated department staff and for audit by the department. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 140.355. Inpatient psychiatric hospital services. (a) Subject to the admission and prior authorization requirements of 7 AAC 140.360 and plan-of-care requirements of 7 AAC 140.365, the department will pay for therapeutically appropriate, medically necessary diagnostic and treatment services for recipients who are admitted to an inpatient psychiatric hospital, including the following services: (1) intake assessment; (2) admitting history and physical examination; (3) individual psychotherapy; (4) group psychotherapy; (5) family psychotherapy; (6) pharmacologic management; (7) crisis intervention; (8) medication administration. (b) Psychiatric services provided in an inpatient psychiatric hospital must be provided (1) under the supervision of a psychiatrist licensed under AS 08.64; and (2) in a manner consistent with an individual plan of care that meets the requirements of 7 AAC 140.365 and is signed by the supervising psychiatrist. (c) Payment for inpatient psychiatric hospital services is limited to services provided to an individual under 21 years of age or an individual 65 years of age and older. (d) In this section, "admitting history and physical examination" means a comprehensive review and examination of a recipient upon admission to an inpatient psychiatric hospital to determine and record the recipient’s (1) medical history; (2) developmental history; (3) social history; (4) present illness or illnesses; (5) basic physical health by means of a complete physical examination; (6) medication history; and (7) allergies, if any. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 140.360. Inpatient psychiatric hospital admission. (a) The department will not pay for inpatient psychiatric hospital services unless the department has authorized the recipient’s admission. Before the department will authorize admission, the department will verify that the requirements of (b) and (c) of this section are met. (b) Upon admission, an inpatient interdisciplinary team that meets the requirements of (d) of this section must


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(1) complete a diagnostic evaluation that (A) includes a psychiatric assessment; (B) is performed no more than 60 days before admission or no more than 72 hours after admission; and (C) indicates the need for inpatient psychiatric services;

(2) certify in the recipient’s medical record that (A) available alternate community resources for ambulatory care do not meet the treatment needs of the recipient, if the recipient is under 21 years of age; (B) proper treatment of the recipient’s psychiatric condition requires services on an inpatient basis, as appropriate; and (C) inpatient psychiatric services can reasonably be expected to improve the recipient’s condition or prevent further regression;

(3) provide to the department (A) the results of the diagnostic evaluation required in (1) of this subsection; (B) the results of a functional assessment; (C) the results of any direct patient observations and assessments obtained following the recipient’s referral; and (D) other information from referral sources, other community agencies, and the family, that is relevant to the recipient’s condition; and

(4) develop a plan of care based upon the information provided under this subsection that meets the requirements of 7 AAC 140.365. (c) Based on the information received under (b)(3) of this section, the department will determine if the proposed treatment and other services are consistent with the recipient’s clinical diagnosis and if they appropriately address the recipient’s needs. (d) An inpatient interdisciplinary team that provides the services required in (b) of this section must, by virtue of education and experience, have the capability of assessing the recipient’s immediate and long-range therapeutic requirements, developmental priorities, personal strengths, liabilities, and the potential resources of the recipient’s family. Except as provided in (f) of this section, an inpatient interdisciplinary team must include (1) either a

(A) psychiatrist licensed under AS 08.64; (B) psychologist licensed under AS 08.86 who has a doctorate degree in clinical psychology and a physician licensed under AS 08.64 to practice medicine or osteopathy; or (C) physician licensed under AS 08.64 to practice medicine who has specialized training and experience in the diagnosis and treatment of mental diseases and a psychological associate licensed under AS 08.86;

(2) a representative of the office of the department responsible for children’s services if the child is in that office’s custody, or a representative of the division of the department responsible for juvenile justice if the child is in that division’s custody; (3) a clinical social worker licensed under AS 08.95; (4) a registered nurse licensed under AS 08.68 who has specialized


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training or one year’s experience in treating mentally ill patients; and (5) depending upon the needs of the recipient, either

(A) an occupational therapist licensed under AS 08.84 who has specialized training or one year’s experience in treating mentally ill patients; or (B) a psychological associate licensed under AS 08.86 who has a master’s degree in clinical psychology.

(e) Upon the admission of a recipient under 21 years of age to an inpatient psychiatric hospital, the provider shall arrange for appropriate EPSDT screening services, in accordance with 7 AAC 110.200 - 7 AAC 110.210. The provider shall ensure that a child has received EPSDT screening (1) no more than the 60 days immediately preceding the date of admission; or (2) no more than five days after the date of admission. (f) Members of the interdisciplinary team of an out-of-state inpatient psychiatric hospital must be licensed by the jurisdiction in which the inpatient psychiatric hospital is located. (g) The department will issue a prior authorization required under this section in accordance with the State of Alaska, Department of Health and Social Services, Behavioral Health Inpatient Psychiatric Review Provider Manual, adopted by reference in 7 AAC 160.900. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 140.365. Inpatient psychiatric hospital plan of care. (a) The individual plan-of-care established by the inpatient interdisciplinary team in accordance with 7 AAC 140.360(b)(4), and a subsequent plan of care review, must (1) be comprehensive and in writing; (2) be developed based upon a diagnostic evaluation as required in 7 AAC 140.360(b)(1); (3) be formulated in consultation with the recipient and the recipient’s family, guardian, or other individual into whose care or custody the recipient will be released following discharge; (4) document individualized treatment objectives and prescribe an integrated program of appropriate therapies, activities, and experiences designed to develop the recipient’s ability to function independently in the recipient’s own environment; (5) include appropriate treatments that are reasonably expected to improve the recipient’s condition to the extent that inpatient psychiatric services will become unnecessary; for a recipient under 21 years of age, the treatment plan must include family psychotherapy unless family psychotherapy is contraindicated; and (6) include a discharge plan prepared at the time of admission and updated during the recipient’s inpatient stay as the recipient’s mental health service needs change, that specifies the approximate date for discharge, the recipient’s anticipated post-discharge service needs, the recipient’s prospective community-based service providers, and other provisions necessary for the transition to a less restrictive environment. (b) The department will review a recipient’s plan of care every 30 days to determine whether the inpatient psychiatric hospital services provided are or were


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required. The department may make recommendations as to necessary adjustments in a plan of care based on the recipient’s response to treatment. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040

Article 6. Residential Psychiatric Treatment Center (RPTC) Services. Section 400. Residential psychiatric treatment center provider requirements 405. Residential psychiatric treatment center admission 410. Residential psychiatric treatment center plan of care 415. Residential psychiatric treatment center services 7 AAC 140.400. Residential psychiatric treatment center provider requirements. (a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing residential psychiatric treatment center (RPTC) services, a provider must (1) be enrolled as an RPTC in accordance with 7 AAC 105.210; (2) if located in this state, be licensed by the department under AS 47.32; (3) if located out of state, meet the licensing and accreditation requirements of the jurisdiction in which the RPTC is located; (4) be accredited by The Joint Commission, the Commission on Accreditation of Rehabilitation Facilities, or the Council on Accreditation of Services for Families and Children as a residential psychiatric treatment center for care of children under 21 years of age; (5) comply with the requirements of 7 AAC 140.400 - 7 AAC 140.415; (6) comply with 42 C.F.R. 483.350 - 483.376, adopted by reference in 7 AAC 160.900, governing the use of restraint and seclusion; and (7) provide basic residential care and services that include

(A) dwelling space provided in separate buildings or units with no more than 60 residential beds per building and no more than 30 beds provided for sleeping accommodation per unit; if the residential unit is part of a larger facility, the residential unit must be a separate and distinct area from other designated psychiatric or treatment units; and (B) equipment, supplies, maintenance, and insurance used by residents for program activities and case-specific services.

(b) The results of required screenings, assessments, evaluations, and certifications must be recorded separately in a written report and included in the recipient’s medical record. (c) An RPTC shall provide an accounting for any funds accepted from the patient for safekeeping. This accounting must be available for inspection by designated department staff and for audit by the department. (d) The department may (1) deny payment to, deny enrollment to, or disenroll a residential psychiatric treatment center in the Medicaid program if the department determines that the facility used a service under 7 AAC 140.415(d); (2) deny enrollment to or disenroll a residential psychiatric treatment center in the Medicaid program if the department determines that the facility

(A) is under investigation, or has been disciplined, by another


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state for a violation that is substantially similar to a violation under 7 AAC 105.400; (B) is no longer accredited by an organization listed in (a)(4) of this section; or (C) does not meet the applicable requirements under 7 AAC 105.120(b)(2) and (3), if the facility is located out of state. (Eff. 2/1/2010, Register 193)

Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 140.405. Residential psychiatric treatment center admission. (a) The department will not pay for RPTC services unless the department has authorized the recipient’s admission. Before the department will authorize admission, the department will verify that the requirements of (b) and (c) of this section are met. (b) Upon admission, an inpatient interdisciplinary team that meets the requirements of (d) of this section must (1) complete a diagnostic evaluation that

(A) includes a psychiatric assessment; (B) is performed before admission or no more than seven days after admission; and (C) indicates the need for RPTC services;

(2) certify in the recipient’s medical record that (A) available alternate community resources for ambulatory care do not meet the treatment needs of the recipient; (B) proper treatment of the recipient’s psychiatric condition requires services on an inpatient or residential basis, as appropriate; and (C) RPTC services can reasonably be expected to improve the recipient’s condition or prevent further regression;

(3) provide to the department (A) the results of the diagnostic evaluation required in (1) of this subsection; (B) the results of a functional assessment; (C) the results of any direct patient observations and assessments obtained following the recipient’s referral; (D) other information from referral sources, other involved community agencies, and the family, that is relevant to the recipient’s condition; and

(4) develop a plan of care based upon the information provided under this subsection that meets the requirements of 7 AAC 140.410. (c) Based on the information received under (b)(3) of this section, the department will determine if the proposed treatment and other services are consistent with the recipient’s clinical diagnosis and if they appropriately address the recipient’s needs. (d) An inpatient interdisciplinary team that provides the services required in (b) of this section must, by virtue of education and experience, have the capability of assessing the recipient’s immediate and long-range therapeutic requirements, developmental priorities, personal strengths, liabilities, and the potential resources of the recipient’s family. Except as provided in (f) of this section, an inpatient interdisciplinary


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team must include (1) either a

(A) psychiatrist licensed under AS 08.64; (B) psychologist licensed under AS 08.86 who has a doctorate degree in clinical psychology and a physician licensed under AS 08.64 to practice medicine or osteopathy; or (C) physician licensed under AS 08.64 to practice medicine who has specialized training and experience in the diagnosis and treatment of mental diseases and a psychological associate licensed under AS 08.86;

(2) a representative of the office of the department responsible for children’s services if the child is in that office’s custody, or an appropriate representative of the division of the department responsible for juvenile justice if the child is in that division’s custody; (3) a clinical social worker licensed under AS 08.95; (4) a registered nurse licensed under AS 08.68 who has specialized training or one year’s experience in treating mentally ill patients; and (5) depending upon the needs of the recipient, either

(A) an occupational therapist licensed under AS 08.84 who has specialized training or one year’s experience in treating mentally ill patients; or (B) a psychological associate licensed under AS 08.86 who has a master’s degree in clinical psychology.

(e) Upon the admission of a recipient under 21 years of age to an RPTC, the RPTC shall arrange for appropriate EPSDT screening services, in accordance with 7 AAC 110.200 - 7 AAC 110.210. The RPTC must ensure that a child has received EPSDT screening (1) no more than the 60 days immediately preceding the date of admission; or (2) no more than five days after the date of admission. (f) Members of the interdisciplinary team of an out-of-state RPTC must be licensed by the jurisdiction in which the RPTC is located. (g) The department will issue a prior authorization required under this section in accordance with the State of Alaska, Department of Health and Social Services, Behavioral Health Inpatient Psychiatric Review Provider Manual, adopted by reference in 7 AAC 160.900. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 140.410. Residential psychiatric treatment center plan of care. (a) The individual plan of care established by the inpatient interdisciplinary team in accordance with 7 AAC 140.405(b)(4) must (1) be comprehensive and in writing; (2) be developed based upon a diagnostic evaluation as required in 7 AAC 140.405(b)(1); (3) be formulated in consultation with the recipient and the recipient’s family, guardian, or other individual to whose care or custody the recipient will be released following discharge;


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(4) document treatment objectives and prescribe an integrated program of appropriate therapies, activities, and experiences designed to develop the recipient’s ability to function independently in the recipient’s own environment; (5) include appropriate treatments that are reasonably expected to improve the recipient’s condition to the extent that RPTC services will become unnecessary; and (6) include a discharge plan prepared at the time of admission and updated during the recipient’s inpatient stay as the recipient’s mental health service needs change, that specifies the approximate date for discharge, the recipient’s anticipated post-discharge service needs, the recipient’s prospective service providers, and other provisions necessary for the transition to a less restrictive environment. (b) The department will review a recipient’s plan of care to determine whether the RPTC services provided are or were required. The department may make recommendations as to necessary adjustments in a plan of care based on the recipient’s response to treatment. The department will do a review every 60 days. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 140.415. Residential psychiatric treatment center services. (a) Subject to the requirements of admission and prior authorization requirements of 7 AAC 140.405 and plan-of-care requirements of 7 AAC 140.410, the department will pay for therapeutically appropriate, medically necessary diagnostic and treatment services for severely emotionally disturbed children, including the following services: (1) individual psychotherapy; (2) group psychotherapy; (3) family psychotherapy; (4) group skill development services; (5) individual skill development services; (6) family skill development services; (7) pharmacologic management and medication administration; (8) crisis intervention; (9) intake assessment. (b) RPTC services must be provided under the direction of a physician. Psychiatric services provided by an RPTC must be provided (1) under the direct supervision of a psychiatrist licensed under AS 08.64; and (2) in a manner consistent with an individual plan of care that meets the requirements of 7 AAC 140.410 and is signed by the supervising psychiatrist. (c) Payment for RPTC services is limited to services provided to an individual under 21 years of age. (d) The department will not pay a residential psychiatric treatment center under this section if the department determines that noncovered services were provided. Noncovered services include (1) holding or rage therapy; (2) verbal abuse and shaming; (3) rebirthing;


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(4) punitive approaches to behavior management, including militaristic-style boot camp and "scared straight" programs; (5) corporal punishment, including slapping, punching, kicking, pinching, shaking, or striking with an object; and (6) therapeutic interventions not specifically directed toward the psychosocial risks and functional impairments of the child. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040

Article 7. Nursing Facility Services: ICF and SNF. Section 500. Nursing facility enrollment and conditions for payment 505. Authorization for admission and determination of level of care 510. Intermediate care facility services 515. Skilled nursing facility services 520. Care plan counseling 525. Transfer from hospital care to nursing facility care 530. Transfer from nonacute care to nursing facility care 535. Continuing placement in a nursing facility 540. Transfer of recipients 545. Discharge of recipients 550. Third-party resources 555. Days chargeable 560. Payment during impending decertification 565. Payment for nursing facility transfers 570. Other payments 575. Recipient personal funds and personal property 580. Required all-inclusive services 585. Absence from nursing facility 590. Medicare coinsurance 595. Definitions 7 AAC 140.500. Nursing facility enrollment and conditions for payment. For a nursing facility to be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing nursing facility services, the following requirements must be met: (1) the nursing facility must

(A) be enrolled with the department under 7 AAC 105.210 as an intermediate care facility or skilled nursing facility; (B) if located out of state, be enrolled in the Medicaid program in the jurisdiction where services are provided; (C) meet all federal utilization control and Medicare long-term care facility requirements under 42 C.F.R. Part 456 and 42 C.F.R. Part 483, adopted by reference in 7 AAC 160.900; and (D) meet all certification and licensing requirements of the jurisdiction in which the nursing facility is located; if located in this state, the nursing facility must be licensed and certified under AS 47.32;

(2) the department has determined under 7 AAC 140.505 that the


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recipient’s medical needs require the level of care that the nursing facility is certified to provide; (3) the department has given prior authorization to the recipient’s placement in the nursing facility. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.070 AS 47.07.030 7 AAC 140.505. Authorization for admission and determination of level of care. (a) The department will authorize an individual for nursing facility services as a new admission, transfer, or continuing placement. Authorization may be given even if an individual is currently receiving services in a general acute care hospital or in an inpatient psychiatric hospital, or nonacute care services in a skilled nursing facility, an intermediate care facility, a home, or other nonacute setting. The department will determine the appropriate level of care by considering (1) the type of care required; (2) the qualifications of the person necessary to provide direct care; and (3) whether the recipient’s overall condition is relatively stable or unstable. (b) To receive payment under 7 AAC 105 - 7 AAC 160, a nursing facility, on a form provided by the department, must request (1) the authorization for admission of the recipient: (2) a level-of-care determination; and (3) a length-of-stay determination. (c) When requesting authorization or reauthorization for admission and a level-of-care determination, a provider shall provide the following information: (1) the medical reason for the stay or continued stay; (2) information supporting the level-of-care decision of the facility’s utilization review committee; (3) the plan of care established for the recipient by the attending physician; (4) the recipient’s diagnosis, symptoms, complaints, and any complication indicating the need for admission or continued stay; (5) a description of the functional level of the recipient; (6) written objectives; (7) an order for medications, treatments, restorative and habilitative services, therapies, diet, activities, social services, and special procedures to meet these objectives; (8) the plans for continuing care, including provision for review and necessary modification of the plan; (9) the reasons why alternative placement is not feasible or appropriate; (10) the plan for discharge. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 140.510. Intermediate care facility services. (a) The department will pay an intermediate care facility for providing the services described in (b) and (c) of this section if those services are


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(1) needed to treat a stable condition; (2) ordered by and under the direction of a physician, except as provided in (c) of this section; and (3) provided to a recipient who does not require the level of care provided by a skilled nursing facility. (b) Intermediate nursing services are the observation, assessment, and treatment of a recipient with long-term illness or disability whose condition is relatively stable and where the emphasis is on maintenance rather than rehabilitation, or care for a recipient nearing recovery and discharge whose condition is relatively stable but who continues to require professional medical or nursing supervision. (c) Intermediate care may include occupational, physical, or speech-language therapy provided by an aide or orderly under the supervision of licensed nursing personnel or a licensed occupational, physical, or speech-language therapist. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 140.515. Skilled nursing facility services. (a) The department will pay a skilled nursing facility for providing skilled nursing described in (b) of this section or structural rehabilitation services described in (c) of this section if those services are (1) needed to treat an unstable condition; (2) ordered by and under the direction of a physician; and (3) provided directly by or under supervision of qualified technical or professional personnel who are authorized by state law to provide that service and who are on the premises at the time service is rendered; technical or professional personnel include a registered nurse, a licensed practical nurse, a licensed physical therapist, a licensed physical therapy assistant, a licensed occupational therapist, a certified occupational therapy assistant, a licensed speech-language pathologist, a registered speech-language pathologist assistant, and an audiologist. (b) Skilled nursing services are the observation, assessment, and treatment of a recipient’s unstable condition requiring the care of licensed nursing personnel to identify and evaluate the recipient’s need for possible modification of treatment, the initiation of ordered medical procedures, or both, until the recipient’s condition stabilizes. (c) Structural rehabilitation services are the following services required by physician orders and provided at least five days a week until the recipient’s condition fails to show continued improvement through objective evidence: (1) ongoing assessment of structured rehabilitation needs and potentials; services must be concurrent with the management of a recipient care plan, including tests and measurements of range of motion, strength, balance, coordination, endurance, functional ability, activities of daily living, perceptual deficiencies, and speech, language, or hearing disorders; (2) therapeutic exercises or activities that, because of the type of exercises employed or the condition of the recipient, must be performed by or under the supervision of a qualified physical therapist or occupational therapist, to ensure the safety of the recipient and the effectiveness of the treatment; (3) gait evaluation and treatment; (4) range-of-motion exercises that are part of the active treatment of a


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specific disease that has resulted in a loss of or restriction of mobility; (5) maintenance occupational or physical therapy if specialized knowledge and judgment of a qualified occupational or physical therapist are required to design and establish a maintenance therapy program based on an initial evaluation and periodic reassessment of the recipient’s needs and consistent with the recipient’s capacity and tolerance; (6) ultrasound, short-wave, and microwave therapy treatments; (7) hot pack, infrared treatments, and paraffin baths in particular cases where the recipient’s condition is complicated by circulatory deficiencies, areas of desensitization, open wounds, fractures, or other complications; (8) services of a communications specialist, a speech-language pathologist, or an audiologist if necessary for the restoration of function in speech or hearing. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 140.520. Care plan counseling. (a) The department will provide care plan counseling to a recipient, or to an individual who may become a recipient, who appears to require placement in a nursing facility before that individual is admitted to the nursing facility. A care plan counselor shall provide an individual with information about alternative methods of meeting the individual’s need for nursing facility care. (b) The department will prepare and submit the nursing facility level-of-care authorization form required by 7 AAC 140.525(c) or 7 AAC 140.530(b) for each individual who receives care plan counseling from the department. (c) The department may exempt an individual from care plan counseling in specific geographic regions of the state if the department determines care plan counseling is impractical because of the low volume of nursing facility admissions, the lack of alternative methods of meeting long-term care needs, or the inability to provide care plan counseling on a timely basis. If an individual in a geographic region is exempted from care plan counseling, the nursing facility that admits the individual must meet the requirements of 7 AAC 140.525, 7 AAC 140.530, or 7 AAC 140.535, whichever is applicable to the recipient. (d) Unless the individual is exempt under (c) of this section, a general acute care hospital, inpatient psychiatric hospital, or nursing facility shall inform the department that an individual is in need of care plan counseling by following the procedure in 7 AAC 140.525, 7 AAC 140.530, or 7 AAC 140.535, whichever is applicable to the recipient. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 140.525. Transfer from hospital care to nursing facility care. (a) This section applies only to a recipient in a general acute care hospital or inpatient psychiatric hospital who appears to require placement in a nursing facility. (b) The department will consider authorizing placement in a nursing facility under this section only if (1) the nursing facility placement of the recipient is cooperatively planned by the recipient’s attending physician, the medical director of the nursing facility, relevant specialists, the director of nursing of the nursing facility, and the discharge


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coordinator of the general acute care hospital or inpatient psychiatric hospital; (2) the discharge coordinator and the director of nursing evaluate the level-of-care needs of the recipient; and (3) the nursing facility submits a preliminary evaluation establishing the need for nursing facility placement; the primary evaluation must be made by

(A) the attending physician; (B) the director of nursing; and (C) any therapist, specialist, or other professional involved in planning for the care of the recipient.

(c) The preliminary evaluation must be included with the request for nursing facility level-of-care authorization on the form provided by the department and include the information required in 7 AAC 140.505(b), unless the recipient is exempt from care plan counseling under 7 AAC 140.520(c). (d) The preliminary evaluation and authorization form must be sent by certified mail, facsimile transmission, or secure electronic transmission, to the department on or before the date of the recipient’s admission to the nursing facility. (e) After evaluating the preliminary evaluation and authorization form, the department will either concur in the placement or request that the nursing facility supply additional information to support the level-of-care placement. If, after reviewing all additional information provided, the department does not find sufficient justification for continued placement in the nursing facility, the department will advise the facility that it has no more than 10 days after the date of notification to transfer or discharge the recipient. If the department approves the placement, the department will notify the facility of the length of the certification and the date on or before which the facility’s utilization review committee must review the placement. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 140.530. Transfer from nonacute care to nursing facility care. (a) This section applies only to a recipient who (1) already receives services in a nursing facility and who appears to require placement in another nursing facility; or (2) is in the recipient’s home or other nonacute care setting and who appears to require placement in a nursing facility. (b) The department will consider authorizing placement in a nursing facility under this section based upon (1) the completed request for nursing facility level-of-care authorization, on the form provided by the department, and that includes the information required in 7 AAC 140.505(b); and (2) the nursing facility’s utilization review committee’s evaluation for the request for nursing facility authorization. (c) The department will evaluate the request for nursing facility level-of-care authorization and the recommendation of the nursing facility’s utilization review committee and either concur in the placement or request that the utilization review committee review additional information to support the level-of-care decision. If the department does not find sufficient justification to continue placement in the nursing facility, the department will advise the facility that it has no more than 30 days after the


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date of notification to arrange for discharge or alternative placement of the recipient. If, at the end of the 30-day period, the recipient has not been discharged or transferred, payment to the facility will be made at the facility’s intermediate care facility rate or the statewide weighted average intermediate care facility rate if the facility does not provide intermediate care. If, at the end of the 30-day period, the recipient has been recommended for discharge and the facility has not yet discharged the recipient, the department will terminate payment. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 140.535. Continuing placement in a nursing facility. (a) The department will consider authorizing the continuing placement of a recipient in a nursing facility if the nursing facility (1) submits a request for nursing facility level-of-care authorization, on a form provided by the department, and that includes the information required in 7 AAC 140.505(b); subsequent request forms must be submitted no less than semiannually following admission to an intermediate care facility and no less than quarterly following admission to a skilled nursing facility; (2) has determined that the level of care is appropriate based upon the recommendation of the nursing facility’s utilization review committee; (3) gives the authorized department representative full access to the nursing facility’s records pertaining to the recipient, including the opportunity for the department representative to personally read charts and records; (4) has included in the recipient’s record a copy of all utilization review committee reports and request for nursing facility level-of-care authorization forms; (5) has written policies that state that only those persons are accepted whose needs can be met by the nursing facility directly or in cooperation with community resources or other providers of care with which the facility is affiliated or has a contract; it is the responsibility of the facility to monitor admissions carefully to ensure that the nursing facility only admits recipients that it has the capability to treat. (b) A nursing facility unable to provide appropriate care for a recipient must notify the department and assist in prompt transfer of that person to a facility that can provide the care needed. (c) If a recipient believes the level-of-care determination is incorrect, the recipient may request a hearing under 7 AAC 49. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 140.540. Transfer of recipients. (a) No later than seven days after a nursing facility transfers a recipient to another level of care within the same facility, the nursing facility must notify the department of the transfer by submitting a current request for a level-of-care authorization on a form provided by the department. (b) Before a nursing facility transfers a recipient to another nursing facility or hospital, the facility shall, at least 10 days before the transfer, provide a written notice (1) to the recipient; (2) if applicable, to the recipient's family or guardian; (3) to the attending physician; (4) to the division of the department responsible for payment for health


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care services; (5) to the division of the department responsible for senior and disabilities services, if the nursing facility is proposing the transfer; and (6) to the nursing facility, if the division of the department responsible for senior and disabilities services is proposing the transfer. (c) A recipient who receives notice of a proposed transfer under (b) of this section may request a hearing under 7 AAC 49. (d) The department may withhold payment to a nursing facility if the facility fails to comply with this section. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.070 7 AAC 140.545. Discharge of recipients. (a) When a nursing facility’s utilization review committee or the department determines that a recipient does not, or in the future will not, require continued nursing facility placement, the nursing facility shall provide, at least 10 days before the date of discharge, a written notice of proposed discharge (1) to the recipient; (2) if applicable, to the recipient's family or guardian; (3) to the attending physician; (4) to the division of the department responsible for payment for health care services; (5) to the division of the department responsible for senior and disability services, if the nursing facility is proposing the discharge; and (6) to the nursing facility, if the division of the department responsible for senior and disability services is proposing the discharge. (b) A recipient who receives notice of a proposed discharge under (a) of this section may request a hearing under 7 AAC 49. (c) The department may withhold payment to the facility, if the facility fails to comply with this section. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.070 AS 47.07.030 7 AAC 140.550. Third-party resources. The department will immediately notify a nursing facility of a known third-party resource or credit available to a recipient, including the amount and source. A recipient’s income, and third-party resources or credits, exclusive of the allowance under 7 AAC 100.554 and 7 AAC 100.558 for personal incidental needs, must be offset as part of the recipient’s cost-of-care liability against the all-inclusive rate in accordance with 7 AAC 145.670. Third-party resources and credits that become known to the nursing facility must be reported to the department. The nursing facility is responsible for collecting those resources or credits. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.070 AS 47.07.030 7 AAC 140.555. Days chargeable. The department will pay from the day of


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admission to a nursing facility but not for the day of discharge, transfer, or death. Transfer includes transfer from one level of care to another level of care within a single nursing facility as well as between different nursing facilities. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.070 AS 47.07.030

7 AAC 140.560. Payment during impending decertification. If the department determines that a nursing facility is deficient in areas relating to recipient care and has initiated decertification proceedings, the department will not pay for services provided to a recipient admitted to the facility, or who becomes eligible for assistance, after the date the department has notified the nursing facility that the department has initiated decertification proceedings. If a nursing facility provides both intermediate care services and skilled nursing services, the department may implement this section independently for each level of certification. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.070 AS 47.07.030 7 AAC 140.565. Payment for nursing facility transfers. (a) If the department determines that a nursing facility is deficient in areas related to recipient care and the facility transfers a recipient to another facility at the same level-of-care certification to avoid decertification or any other enforcement penalty, the department will recover from the facility the costs of transferring that recipient to the other facility. (b) If the department determines that a recipient needs a higher or lower level of care than the facility is certified to provide, the department will pay the cost of moving the recipient to a facility certified to provide a higher or lower level of care. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.070 AS 47.07.030 7 AAC 140.570. Other payments. Payment by the department is payment in full for those services authorized under Medicaid. If the nursing facility obtains from another source any additional payment for the care provided to a recipient for services that have been paid for by Medicaid, the nursing facility shall refund or credit the additional payments to the department. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.070 AS 47.07.030 7 AAC 140.575. Recipient personal funds and personal property. (a) A recipient has the right to manage the recipient’s personal funds unless the recipient has been adjudicated incapacitated or the recipient’s incapacity has been established in accordance with AS 13.26.353, or the recipient has had a full guardian appointed under AS 13.26.116 or a conservator appointed under AS 13.26.165. A recipient or a recipient’s representative may delegate holding, safeguarding, accounting, or managing responsibilities to a nursing facility. If a recipient or a recipient’s representative delegates holding, safeguarding, accounting, or managing responsibilities to a nursing


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facility, the nursing facility shall make the account required under 42 C.F.R. 483.10(c), adopted by reference in 7 AAC 160.900, available to the recipient. The account may be used to hold the recipient’s personal funds, including the amount set aside for the recipient’s personal needs allowance under 7 AAC 100.558. Recipient personal funds may be used to purchase personal incidental items, supplies, or services not otherwise furnished by the nursing facility or covered by Medicaid. (b) If a recipient delegates holding, safeguarding, accounting, or managing responsibilities to the nursing facility under (a) of this section, the nursing facility must (1) have on file a copy of a written delegation; (2) provide a written receipt to the recipient each time the facility receives the recipient’s personal funds; (3) deposit the personal funds in a bank in a separate account, apart from any other bank account or accounts of the facility; if any interest is earned on the account, the interest must be apportioned in accordance with the amount of the recipient’s personal funds; (4) maintain an account record for the recipient; the account record must show in detail, with supporting verification, the amount of personal funds received or disbursed on behalf of the recipient; (5) without charge, provide to a recipient at least quarterly, an accounting of financial transactions made on the recipient’s behalf; (6) notify the recipient and the department when the recipient’s accumulated personal funds exceed $1,500; (7) make the recipient’s personal funds available to the recipient upon request during normal banking hours; (8) require a list of purchased items, including a description and price, and a receipt, for all items purchased by any person shopping for the recipient, including facility staff, an aide, a volunteer, a department employee, and a family member; and (9) get permission from the recipient or the recipient’s representative before withdrawing any amount from the recipient’s personal funds. (c) Upon discharge or transfer, the nursing facility shall pay to a recipient 90 percent of the recipient’s personal funds on deposit with the nursing facility in the recipient’s name. No more than 30 days after discharge or transfer, the facility shall give to the recipient a final accounting of the recipient’s personal funds and a check for any balance on deposit. (d) The nursing facility shall retain, for three years, receipts for expenditures from a recipient’s personal funds, together with the recipient’s account record. (e) Upon sale or other transfer of an ownership interest in a nursing facility or a contract to provide nursing home services in a facility, both the transferor and transferee share joint responsibility in transferring the recipient’s personal funds and records in an accurate and orderly manner. (f) A nursing facility may not charge a Medicaid recipient for items or services if the facility does not charge all non-Medicaid recipients for those same items and services. Charges must be for direct, identifiable services or supplies furnished to an individual recipient. A periodic "flat" rate charge for routine items, including beverages or cigarettes, is not allowed. A nursing facility may only charge for a service after it has provided the service, and for an item after it has delivered it. Charges may not exceed


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actual cost to the nursing facility. (g) At a recipient’s request, a nursing facility shall hold and safeguard a recipient’s nonmonetary personal property. A recipient’s personal property must be clearly marked with the recipient’s name. The nursing facility shall keep an up-to-date record of personal property separate from the facility’s inventory. If items are lost, the circumstances of disappearance shall be documented in the nursing facility’s records. (h) The nursing facility may not charge a recipient for holding, safeguarding, accounting, or managing personal funds or personal property. The cost of accounting and handling must be included in the facility’s cost of operation. (i) The department may withhold payment to a nursing facility if the facility fails to record properly the receipt and disposition of a recipient’s personal funds or personal property. (j) In this section, (1) "delegate" means to give legal authority to a person or an entity in writing; and (2) "personal funds" means money or other liquid assets owned by a recipient that are set aside for use by or on behalf of a resident of a nursing facility. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 140.580. Required all-inclusive services. (a) A nursing facility shall provide rehabilitative nursing care, including the services of restorative aides and nurses, as part of nursing and supportive care services. (b) If a recipient needs nonemergency, continuous heavy use of oxygen, the nursing facility shall make it available for use at all times. The nursing facility shall submit a request for authorization, on a form provided by the department, shall provide on that form a detailed description of the recipient’s need for continuous heavy use of oxygen, and shall include physician orders or physician or nursing notes. Payment will be made to the nursing facility at the facility’s cost for the oxygen. The amount of oxygen given to the recipient must be accurately metered and measurable to the recipient. On the billing, the nursing facility shall note the metered amount of oxygen and dates used. (c) A nursing facility is responsible for transportation planning. To determine the appropriate type of carrier, the nursing facility shall consider the recipient’s condition, distance to the medical facility or provider of service, and the frequency of the trip. The least expensive mode of transportation must be used consistent with these conditions. (d) Nonemergency, in-state transportation must receive prior authorization from the department. Emergency transportation must be reported to the department as soon as possible but not later than three working days after the transportation occurred. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.070 AS 47.07.030 7 AAC 140.585. Absence from nursing facility. (a) Except as provided in (b) of this section, the department will pay for reserving a bed during a planned temporary absence of a recipient from a nursing facility if the absence is not more than 12


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consecutive days and the time of departure and return of the recipient are recorded in the nursing facility’s records. A planned temporary absence of not more than 12 consecutive days for which the department will pay for reserving a bed includes (1) a visit with relatives and friends; and (2) leave to participate in therapeutic or rehabilitative programs, including

(A) trial visits to alternative care settings to determine if permanent placement is feasible; (B) gradually increasing lengths of visits to prepare recipients for return to their home or community; and (C) an extended absence to participate in workshop evaluation for rehabilitative programs.

(b) The department will not pay for reserving a bed during a temporary absence of more than 12 consecutive days, unless the department gives prior authorization for the absence. The department will not pay for reserving a bed if the recipient has total absences in excess of 12 days during a 12-month period, unless the department gives prior authorization for the absence. The facility must submit a request in writing and receive written approval from the department before the recipient leaves the nursing facility. (c) In the recipient’s plan of care, the nursing facility shall document the purpose and plan of a therapeutic or rehabilitative absence. (d) If a recipient leaves a nursing facility for hospitalization, the department will not pay to reserve the recipient’s bed at the nursing facility. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 140.590. Medicare coinsurance. (a) The department will pay, on behalf of a recipient, the coinsurance established under part A of Medicare for care rendered from the 21st through the 100th day of care in a nursing facility. The department will pay the nursing facility rate established for care in that particular facility beyond the 100th day. (b) Rejection or nonpayment by Medicare of services provided by a nursing facility because the services were custodial in nature or because the facility did not choose to participate as a Medicare provider is not, by itself, justification for the department to make full payment to a nursing facility during the period from the 1st to the 100th day of care at a nursing facility. The department will make payment to the nursing facility in accordance with the level of care appropriate to the recipient’s needs as determined by the nursing facility’s utilization review committee and approved by the department. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 140.595. Definitions. In 7 AAC 140.500 - 7 AAC 140.595, (1) "licensed nursing personnel" means those persons who are registered nurses or licensed practical nurses; (2) "utilization review committee" means the facility-based medical review team composed of private physicians and other professional persons. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040


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Article 8. Intermediate Care Facility for the Mentally Retarded Services.

Section 600. ICF/MR enrollment and conditions for payment 605. ICF/MR interdisciplinary teams 610. Records, habilitative plan of care, treatment, and reevaluation 615. Required all-inclusive services 620. Absence from an ICF/MR 625. Transfer of recipients 630. Discharge of recipients 635. Applicability of other sections 640. Qualified mental retardation professionals 7 AAC 140.600. ICF/MR enrollment and conditions for payment. (a) For an intermediate care facility for the mentally retarded (ICF/MR) to be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing intermediate care services for the mentally retarded, the following requirements must be met: (1) the ICF/MR must

(A) be enrolled in accordance with 7 AAC 105.210 as an ICF/MR; (B) if located out of state, be enrolled in the Medicaid program in the jurisdiction where services are provided; (C) meet all federal standards for payment and certification requirements under 42 C.F.R. Part 442, adopted by reference in 7 AAC 160.900; (D) meet all certification and licensing requirements of the jurisdiction in which the ICF/MR is located; if located in this state, the ICF/MR must be certified under AS 47.32; (E) comply with 7 AAC 140.600 - 140.640, 7 AAC 150, and other applicable requirements of 7 AAC 105 - 7 AAC 160; and (F) meet the requirements of (b) of this section;

(2) the department has determined that the recipient’s medical needs require the level of care provided in an ICF/MR, as determined under (c) and (d) of this section. (b) The department will authorize payment for services in an ICF/MR only if the facility (1) provides a comprehensive medical, social, and psychological evaluation of each recipient, covering physical, emotional, social, and cognitive factors of each recipient’s need for care and services; the facility must complete the evaluation no more than 30 days after the date of the

(A) recipient’s admission to the facility; or (B) request for payment under Medicaid, if the recipient is a resident of the facility who applies while in the facility; and

(2) submits annually, for each state fiscal year and on a form approved by the department, a request for ICF/MR authorization that, for

(A) the first request, explains the reason for admission and provides a detailed summary of the recipient’s habilitative plan of care developed as required in 7 AAC 140.610(a); and


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(B) subsequent requests, provides a detailed summary of the reevaluation of the recipient as required in 7 AAC 140.610(c).

(c) In determining whether a recipient qualifies under this section for ICF/MR services, the department will base its decision on the determination of a qualified mental retardation professional within the department that the recipient meets the functional criteria in (d) of this section, and that the recipient has at least one of the following conditions: (1) mental retardation that meets the diagnostic criteria for code 317 or 318.0, 318.1, or 318.2, as set out in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, adopted by reference in 7 AAC 160.900; the recipient must have an intelligence quotient of 70 points or less as determined by an individual, standardized psychological evaluation, plus up to five points to account for any measurement error; (2) a condition that is

(A) one other than mental illness, psychiatric impairment, or a serious emotional or behavioral disturbance; and (B) found to be closely related to mental retardation because that condition results in impairment of general intellectual functioning and adaptive behavior similar to that of individuals with mental retardation; the condition must be diagnosed by a licensed physician and require treatment or services similar to those required for individuals with mental retardation;

(3) cerebral palsy that is diagnosed by a licensed physician; however, a deficit in intellectual ability need not be present; (4) seizure disorder that is diagnosed by a licensed physician; however, a deficit in intellectual ability need not be present; (5) autism that has been diagnosed by a mental health professional clinician and that meets the diagnostic criteria for code 299.00, as set out in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, adopted by reference in 7 AAC 160.900. (d) Each condition identified in (c) of this section must (1) have originated before the age of 22 years; (2) be likely to continue indefinitely; and (3) constitute a substantial disability to the individual’s ability to function in society, as

(A) measured by the Inventory for Client and Agency Planning (ICAP), adopted by reference in 7 AAC 160.900; and (B) evidenced by a broad independence domain score equal to or less than the cutoff scores in the department’s Table of ICAP Scores by Age, adopted by reference in 7 AAC 160.900.

(e) No more than 120 days after the date it receives a request for ICF/MR authorization, the department will evaluate that request in accordance with (a) of this section and make a determination. In that determination, the department will concur in the placement and authorize payment, deny authorization for payment, or request that the interdisciplinary team assigned under 7 AAC 140.605 provide additional information. (f) If the department, as part of its determination under (c) of this section, finds that sufficient justification does not exist to continue a recipient’s placement in a facility,


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the department will recommend to the facility that alternative placement be found or the recipient be discharged. The department will give the facility 30 days after the date of the determination for the facility to arrange for discharge or alternative placement of a recipient. At the end of that 30-day period, if the recipient has been recommended for discharge and the facility has not yet discharged the recipient, the department will terminate payment to the facility. (g) A facility that is denied authorization for payment may appeal under 7 AAC 105.280. A recipient whose continued placement is denied may request a hearing under 7 AAC 49. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 140.605. ICF/MR interdisciplinary teams. (a) An ICF/MR shall assign a recipient an interdisciplinary team, to be directly involved in the treatment of the recipient, and to develop, implement, monitor, and evaluate the habilitative plan of care required under 7 AAC 140.610. An interdisciplinary team must include, at a minimum, (1) the recipient; (2) the recipient’s

(A) family members, including parents, guardians, siblings, and others similarly involved in providing general oversight of the recipient; or (B) legal guardian, if any;

(3) at least one qualified mental retardation professional; and (4) other professionals involved in the recipient’s care. (b) Each member of the interdisciplinary team shall attend meetings of the team in person or by telephone and be involved in team decisions unless the clinical record, as maintained under 7 AAC 140.610, documents that (1) the other team members determine that participation by the recipient or other individual involved with the care of the recipient is detrimental to the recipient’s well being; (2) family members refuse to participate after the provider’s diligent efforts to encourage participation; or (3) weather, illness, or another circumstance beyond a member’s control prohibits that member from participating. (c) If a provision of 7 AAC 140.600 - 7 AAC 140.640 requires the approval, concurrence, or recommendation of the interdisciplinary team, the interdisciplinary team may issue that approval, concurrence, or recommendation only upon the concurrence of (1) each team member under (a)(3) of this section; (2) the recipient or the recipient’s representative; and (3) a majority of the team members other than the members identified in (1) and (2) of this subsection. (d) The facility shall notify all absent members of the proceedings and decisions of the interdisciplinary team meeting. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 140.610. Records, habilitative plan of care, treatment, and reevaluation. (a) An ICF/MR shall maintain a clinical record of services provided to a recipient. The clinical record must include the evaluation required in 7 AAC


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140.600(b)(1). The clinical record must also include a written, individualized habilitative plan of care that includes (1) information identifying the recipient; (2) a list of the members of the interdisciplinary team organized under 7 AAC 140.605; (3) a prioritized summary of the presenting problems and needs as identified during the evaluation; (4) a description of the functional level of the recipient; (5) diagnoses, symptoms, complaints, and complications indicating the need for admission or continued stay; (6) clearly stated measurable goals or behaviorally stated objectives derived from the evaluation and designed to attain or maintain the optimal physical, intellectual, social, or vocational functioning of which the recipient is presently or potentially capable; (7) orders, as appropriate, for services that are individually designed to accomplish the stated goals and objectives, including medications, treatment, habilitation services, nutrition services, social services, therapies, experiences, activities, and any special procedures; in this paragraph, "habilitation services" has the meaning given in 7 AAC 130.319; (8) reasons why alternative placement is not feasible or appropriate; (9) a plan for discharge and for care following discharge to assure the maximum development of self-help and living skills; that plan must include provision for appropriate services, protective supervision, and other follow-up services in the recipient’s new environment; (10) documentation that the recipient or the recipient’s representative actively participated in the development of the habilitative plan of care, or if active involvement is not possible, a statement of the reasons for the lack of participation; and (11) signatures of the following individuals, indicating review and approval:

(A) the recipient or the recipient’s representative, unless the recipient or the recipient’s representative is not willing or able to participate as described in (10) of this subsection; (B) at least one physician or qualified mental retardation professional; (C) those participating members of the interdisciplinary team organized under 7 AAC 140.605 who have reviewed and approved the plan.

(b) An ICF/MR must provide (1) a protected residential setting, individualized ongoing evaluation, planning, 24-hour supervision, and coordination and integration of health and habilitative services to help a recipient reach maximum functioning capability; and (2) in accordance with the recipient’s habilitative plan of care, regular participation by the recipient in professionally developed and supervised activities, experiences, or therapies, including recreation and day programming. (c) At least once a year, the interdisciplinary team assigned under 7 AAC 140.605 shall perform a medical, social, and psychological reevaluation, including a review of the recipient’s progress toward meeting the goals and objectives stated in the


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recipient’s habilitative plan of care, the appropriateness of that plan of care, an assessment of the continuing need for institutional care, and consideration of alternate methods of care. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 140.615. Required all-inclusive services. (a) If a recipient needs non-emergency, continuous heavy use of oxygen, the ICF/MR shall make it available for use at all times. The facility shall submit a request for authorization, on a form provided by the department, shall provide on that form a detailed description of the recipient’s need for continuous heavy use of oxygen, and shall include physician orders or physician or nursing notes. Payment will be made to the ICF/MR at the facility’s cost for the oxygen. The amount of oxygen given to the recipient must be accurately metered and measurable to the recipient. In the billing, the ICF/MR shall note the metered amount of oxygen and dates used. (b) An ICF/MR is responsible for transportation planning. To determine the appropriate type of carrier, the facility shall consider the recipient’s condition, distance to the medical facility or provider of service, and the frequency of the trip. The least expensive mode of transportation must be used consistent with these conditions. (c) Nonemergency, in-state transportation must be given prior authorization by the department. Emergency transportation must be reported to the department as soon as possible but not later than three working days after the transportation occurred. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 140.620. Absence from an ICF/MR. (a) Except as provided in (b) of this section, the department will pay for reserving a bed during a planned temporary absence of a recipient from an ICF/MR if (1) the absence is not more than 12 consecutive days; (2) the time of departure and return of the recipient are recorded in the facility’s records; and (3) the absence is for a visit with relatives or friends. (b) The department will not pay for reserving a bed during a temporary absence of more than 12 consecutive days, unless the department gives prior authorization for the absence. The department will not pay for reserving a bed if the recipient has total absences in excess of 12 days during a 12-month period, unless the department gives prior authorization for the absence. The ICF/MR must submit a request in writing to the department for any absence in excess of 12 days and receive written approval from the department before the recipient leaves the facility. The department will authorize leaves of any duration to participate in therapeutic or rehabilitative programs that include (1) trial visits to alternative care settings to determine if permanent placement is feasible; (2) gradually increasing lengths of visits to prepare recipients for return to their home or community; and (3) extended absence to participate in workshop evaluation for rehabilitative programs. (c) In the recipient’s plan of care, the ICF/MR shall document the purpose and


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plan of a therapeutic or rehabilitative absence. (d) A recipient temporarily absent overnight or longer from the facility on activities paid for and supervised by the facility will be considered as remaining in the facility. In this subsection, "activities" includes specific trips of an educational or training nature and recreational activities, including camping, fishing, and hiking. (e) If a recipient leaves an ICF/MR for hospitalization, the department will not pay to reserve the recipient’s bed at the ICF/MR. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 140.625. Transfer of recipients. (a) Transfer to another ICF/MR may not occur without 30 days’ prior written notice to the recipient and, if appropriate, the family or guardian, and to either the department or the facility, depending on whether the department or the facility is proposing the transfer. Recipients who receive notice of a proposed transfer have the hearing rights set out in 7 AAC 49. (b) The department may withhold payment to an ICF/MR if the facility fails to comply with this section. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 140.630. Discharge of recipients. (a) If the interdisciplinary team assigned under 7 AAC 140.605 or the department recommends that a recipient does not, or in the future will not, require continued placement in an ICF/MR, the recipient and, where appropriate, the family or guardian, and either the department or the facility, depending on whether the department or the facility is proposing the discharge, must be given 30 days’ written notice before discharge. Recipients who receive notice of a proposed discharge have the hearing rights set out in 7 AAC 49. (b) The department may withhold payment to an ICF/MR if the facility fails to comply with this section. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 140.635. Applicability of other sections. The provisions of 7 AAC 140.550 - 7 AAC 140.575 also apply to and ICF/MR except where they conflict with specific provisions of 7 AAC 140.600 - 7 AAC 140.640. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 140.640. Qualified mental retardation professionals. To be considered a qualified mental retardation professional for purposes of 7 AAC 140.600 - 7 AAC 140.640, an individual must meet the standard for a qualified mental retardation professional set out in 42 C.F.R. 483.430(a), adopted by reference in 7 AAC 160.900. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040


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Chapter 145. Medicaid Payment Rates. Article 1. Medicaid Payment; Conditions and Methods (7 AAC 145.005 - 7 AAC 145.025) 2. RBRVS Methodology (7 AAC 145.050) 3. Payment Rates; Professional Services (7 AAC 145.100 - 7 AAC 145.280) 4. Payment Rates; Therapies and Related Services (7 AAC 145.300 - 7 AAC 145.350) 5. Payment Rates; Prescription Drugs and Medical Supplies; DME; Transportation;

Laboratory (7 AAC 145.400 - 7 AAC 145.460) 6. Payment Rates; Personal Care and Home Health Care Services (7 AAC 145.500 -

7 AAC 145.510) 7. Payment Rates; Home and Community-Based Waiver Services (7 AAC 145.520 -

7 AAC 145.540) 8. Payment Rates; Behavioral Health Services (7 AAC 145.580) 9. Payment Rates; Facility and Facility-Based Services (7 AAC 145.600 - 7 AAC

145.690) 10. Payment Rates; Rural Health Clinic and Federally Qualified Health Center Services

(7 AAC 145.700 - 7 AAC 145.739)

Article 1. Medicaid Payment; Conditions and Methods. Section 05. Conditions for payment 10. Prohibition against reassignment 15. Payment reduced by cost-sharing 20. Methodology used to establish provider payment rates 25. Payment for services provided out of state 7 AAC 145.005. Conditions for payment. (a) The department will pay for a covered service identified in AS 47.07 and 7 AAC 105 - 7 AAC 160 only if the (1) provider is enrolled with the department; (2) services were rendered to an individual who was eligible under 7 AAC 100 at the time the service was rendered; and (3) the department gave prior authorization for the service if required under 7 AAC 105 - 7 AAC 160. (b) The payment rate established by the department for a given service, less the amount of cost-sharing required under 7 AAC 105.610, constitutes full payment from the department for that service. Except as provided in 7 AAC 110.145, a provider may not charge a recipient or recipient's, relative, friend, or representative, any amount to supplement payment by the department for services to which the recipient is entitled under 7 AAC 105 - 7 AAC 160. (c) A provider must submit a claim to the department’s contractor no more than 12 months after the date of service except as provided in this subsection. The department may extend the 12-month deadline for billing if the department determines that the provider had reason to believe that the recipient was ineligible at the time service was rendered, the recipient is subsequently determined eligible by a court, hearing authority, or the department, and the claim is filed no more than 12 months after the date the department sends notice to the recipient of the court, hearing authority, or department


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decision that eligibility is established. The recipient’s failure to notify the provider of a court, hearing authority, or department decision is not considered good cause under 7 AAC 105.280 for failure to file a claim. (d) Except as specified in (e) of this section, when a provider furnishes a covered service to a recipient who, before receiving the service, has furnished the provider with a recipient identification card, recipient identification number, or other evidence of Medicaid eligibility, the recipient is under no obligation to pay the provider for the service other than the cost-sharing amounts required under 7 AAC 105.610. However, a recipient is liable for the full cost of the service rendered if the recipient fails to furnish a recipient identification card, recipient identification number, or other evidence of Medicaid eligibility before receiving the service. (e) If a recipient is eligible retroactively under 7 AAC 100.072, the provider is under no obligation to submit a claim to the department for a covered service furnished to the recipient during a month the recipient was found retroactively eligible. The recipient remains liable for the cost of the service rendered during a month of retroactive eligibility until the provider has been furnished evidence of eligibility and the provider has agreed to accept payment under (g) and (h) of this section and 7 AAC 145.020 by billing the department for the service. Payments made by a recipient to the provider before retroactive eligibility has been determined by the department must be handled in accordance with 7 AAC 105.250. (f) The department will deny a claim for payment if the provider fails to submit the claim in the form or format required by the department for claim submission. If a payment is denied under this section, the provider may appeal under 7 AAC 105.270. (g) By providing a service to a Medicaid recipient and billing the department for that service, a provider agrees to comply with applicable department regulations. (h) A provider may not charge (1) for any administrative cost related to participation in the Medicaid program; or (2) a higher rate for any unit of service provided to a Medicaid recipient than the provider charges others, except for an amount billed Medicare. (i) If a provider receives a payment from a recipient, relative, recipient’s estate, health insurance, or other source for a service provided, and the provider intends to submit a claim to the department for the same service, the provider must report that payment and must enter it as a credit against the charge to the department. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.042 7 AAC 145.010. Prohibition against reassignment. (a) The department will not make payment on a claim known by a provider to be covered by Medicaid if the claim has been assigned, sold, or transferred, including transfers through the use of power of attorney, to a collection agency, service bureau, or individual who advances money to a provider for the provider’s accounts receivable. (b) The use of a billing agent or accounting firm that bills and receives payment in the name of the provider is permitted if payment for this service is not related on a percentage or other basis to the amount to be billed or collected. (Eff. 2/1/2010, Register 193)


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Authority: AS 47.05.010 AS 47.07.040 7 AAC 145.015. Payment reduced by cost-sharing. Payment provided by the department will be reduced by the amount of cost-sharing required under 7 AAC 105.610, and represents full payment from the department for those covered services authorized under Medicaid. A recipient may be charged only for the amount of cost-sharing specified in 7 AAC 105.610 and may not be charged for any additional difference between the amount billed and the amount received in payment from the department for those covered services provided. A recipient is responsible for payment of the cost-sharing amounts required under 7 AAC 105.610 and for payment of all services not covered under Medicaid. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.042 7 AAC 145.020. Methodology used to establish provider payment rates. (a) Regardless of the payment methodology or payment rate adopted under 7 AAC 105 - 7 AAC 160, and except as provided in 7 AAC 155.010 with regard to tribal health programs, the department will pay a provider for a covered service at the lowest of the (1) specific payment rate established in 7 AAC 105 - 7 AAC 160; (2) provider’s billed charges; or (3) provider’s lowest charge that is advertised, quoted, posted, billed, or discounted for any other purchaser of services for that unit of service and provided on the same date, determined in accordance with (b) of this section. (b) When determining the provider’s lowest charge under (a) of this section, the department will not consider (1) a sliding fee scale established in writing that is based upon income for families and individuals with income equal to or less than 250 percent of the applicable federal poverty guidelines for this state, as adopted by reference under 7 AAC 160.900(f); (2) any single contract that contains a discounted rate for a service or group of services and that does not exceed 20 percent of a provider’s annual gross income; (3) a reduced rate for a service or group of services the provider offers to the provider’s employees as part of an employee benefit package; or (4) a contract with a federal or state government agency. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 7 AAC 145.025. Payment for services provided out of state. (a) Unless otherwise provided in 7 AAC 105 - 7 AAC 160, the department will pay an out-of-state enrolled provider at the lowest of (1) the billed charges; (2) 70 percent of the in-state rate identified in 7 AAC 105 - 7 AAC 160 for the specific type of provider; or (3) the rate established by the Medicaid agency in the jurisdiction where the service was provided, if the rate information is available. (b) The department may negotiate a specific payment agreement for unique


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expertise, for specialized services not available in this state, or for specific services that are necessary to treat the recipient. Factors that the department will consider in making the decision to negotiate a specific payment agreement under this subsection include (1) the medical necessity for the out-of-state service; (2) whether the service is widely available out of state or available only from a limited number of out-of-state providers; (3) the professional standing of the provider within the health care services community for the unique expertise or specialized service; (4) any extreme circumstance concerning the medical needs of the patient; and (5) whether a specific payment agreement is necessary to ensure access to appropriate medical services that otherwise would not be available. (c) The specific payment agreement under (b) of this section is not available for general services offered by the provider and is limited to the specific services set out in the payment agreement. General services offered by the provider and not associated with unique expertise or the specialized services outlined in the payment agreement will be paid under (a) of this section. (d) The specific payment agreement under (b) of this section must be for a specific period of time, not to exceed two years. (e) Except as provided in this section, the department will process claims for out-of-state services in accordance with the claim process established for the applicable types of provider in this state under 7 AAC 105 - 7 AAC 160. (f) Charges to the department for out-of-state services may not exceed the provider’s usual and customary charges for the same service to the general public. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040

Article 2. RBRVS Methodology. Section 50. Resource-based relative value scale rate-setting methodology 7 AAC 145.050. Resource-based relative value scale rate-setting methodology. (a) Except as otherwise provided in 7 AAC 105 - 7 AAC 160 for certain types of providers or services, the department will establish fees for use in payment for each type of provider and service subject to 7 AAC 105 - 7 AAC 160 using the resource-based relative value scale (RBRVS) methodology described in this section. (b) The RBRVS methodology set out in this section is for procedures that have a Medicare nonfacility individual relative value unit (RVU) established for Medicare by CMS for each medical procedure. Medicare nonfacility individual RVUs are adopted by reference in 7 AAC 160.900. The RBRVS payment for these procedures consists of (1) an RVU that contains

(A) a work component (RVUw) that is measured by the time and intensity of effort required to provide a service; (B) a practice expense component (RVUp) that includes costs related to the provision of services, including rent, salaries, equipment, and supplies; and


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(C) a malpractice expense component (RVUm) that is measured by professional liability insurance premium costs;

(2) a geographic practice cost index (GPCI) that is set as an adjustment factor that modifies each RVU to reflect the cost of practice in this state; each GPCI contains

(A) a work component (GPCI Work); (B) a practice expense component (GPCI PE); and (C) a malpractice expense component (GPCI MP); and

(3) a conversion factor that is a dollar amount set by the department and used to convert each RVU into a fee amount; this conversion factor is $45.90. (c) The fee for each procedure subject to RBRVS-based payment is determined using the following calculation: [(RVUw X GPCI Work) + (RVUp X GPCI PE) + (RVUm X GCPI MP)] X $45.90. (d) The department will pay for anesthesiology services in accordance with the following calculation: ($42.90 X the number of base units for anesthesiology services) + ($36 X the number of time units), where the number of base units is determined in accordance with the Relative Value Guide, adopted by reference in 7 AAC 160.900, and the value of one time unit is 10 minutes. The department will not make an additional payment for a physical status modifier as set out in Current Procedural Terminology, adopted by reference in 7 AAC 160.900. (e) Except as provided in (f) of this section, and subject to 7 AAC 145.020, if a procedure does not have an RVU established for Medicare by CMS, and is not subject to another payment methodology or fee under this chapter, the department’s payment for a covered procedure will not exceed 80 percent of billed charges for the first nine billings that reflect a charge for the service that complies with the applicable standards in 7 AAC 145.020. Thereafter, the fee will be established based on the 90th percentile of the first 10 billings. To be paid under this subsection, a billing must reflect a charge for the procedure that complies with the applicable standards in 7 AAC 145.020. No more than three claims from a provider, group, or pay-to-provider will be used to establish a fee under this chapter. The department will periodically review and adjust specific payment rates established under this subsection. (f) The department’s payment for an item or service described as an "unlisted procedure," "not otherwise classified (NOC)," or "not otherwise specified" will not exceed 50 percent of billed charges if the department agrees that the item or service cannot be billed under another code, and if the billing reflects a charge for the item or service that complies with the applicable standards in 7 AAC 145.020. (g) The department will not make an additional payment for an unusual procedural service identified as modifier -22 in the list of modifiers set out in Current Procedural Terminology, adopted by reference in 7 AAC 160.900. (h) For providers who are not required to enroll under 7 AAC 120.200, the department will pay for nonroutine office medical and surgical supplies in accordance with the same methodology and rates established in 7 AAC 145.420. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040


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Article 3. Payment Rates; Professional Services. Section 100. Advanced nurse practitioner services payment rates 110. Chiropractic services payment rates 120. Dental services payment rates 130. Direct-entry midwife services payment rates 140. Payment for EPSDT services 150. Family planning services payment rates 160. Imaging services payment rates 170. Nurse anesthetist payment rates 180. Nutrition services payment rates 200. Physician services payment rates 220. Physician surgical procedures payment rates 240. Podiatry services payment rates 250. Private-duty nursing rates 260. Psychologist services payment rates 265. Targeted case management payment rates 270. Telemedicine payment rates 280. Vision examinations and services payment rates 7 AAC 145.100. Advanced nurse practitioner services payment rates. (a) Except as provided in (e) of this section, the department will pay an in-state advanced nurse practitioner, including nurse midwife, in accordance with 7 AAC 145.020, not to exceed 85 percent of the rate determined under 7 AAC 145.050. (b) The department will pay an out-of-state advanced nurse practitioner the rate determined under 7 AAC 145.025. (c) The department will pay an advanced nurse practitioner acting as a surgical assistant the lesser of the billed charges or 25 percent of the rates established for an advanced nurse practitioner under (a) of this section. The department will not pay for an advanced nurse practitioner as the primary surgeon. (d) The department will not pay separately for office medical supplies and services associated with office visits and procedures because they are included in the practice expense component of the RBRVS methodology used in 7 AAC 145.050. The department will pay for nonroutine office medical and surgical supplies in accordance with 7 AAC 145.050(h). (e) The department will pay an advanced nurse practitioner certified as a nurse midwife for a normal vaginal delivery performed at a free-standing birth center licensed under AS 47.32, the lesser of (1) billed charges for the free-standing birth center services; in this paragraph, "billed charges" includes charges for the nurse midwife services, birth center use, nursing, other facility support staff, medication, and supplies related to the normal uncomplicated delivery; or (2) 85 percent of the rate identified under (a) of this section for the vaginal delivery plus 50 percent of the statewide average allowed amount under 7 AAC 105 - 7 AAC 160 for normal vaginal hospital delivery with a one-day length of stay during the calendar year ending 12 months before the beginning of the rate year; this


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amount is calculated each calendar year as the total allowed amount under 7 AAC 105 - 7 AAC 160 for hospitals for normal vaginal deliveries with a one-day length of stay designated by a primary diagnosis code of 650 as described in the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), adopted by reference in 7 AAC 160.900, divided by the total number of related deliveries. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 145.110. Chiropractic services payment rates. (a) The department will pay an in-state chiropractor in accordance with 7 AAC 145.020, not to exceed 100 percent of the amount determined under 7 AAC 145.050. (b) The department will pay an out-of-state chiropractor in accordance with 7 AAC 145.025. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 145.120. Dental services payment rates. (a) The department will pay a dentist for dental services provided to a recipient 21 years of age or older in accordance with the CDT Procedure Codes: Emergent Dental Services for Adults table and CDT Procedure Codes: Enhanced Dental Services for Adults table adopted by reference in 7 AAC 160.900. (b) The department will pay a dentist for dental services provided to a recipient under 21 years of age in accordance with the CDT Procedure Codes: Dental Services for Children table adopted by reference in 7 AAC 160.900. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 145.130. Direct-entry midwife services payment rates. (a) The department will pay an in-state direct-entry midwife in accordance with 7 AAC 145.020, not to exceed 85 percent of the amount determined under 7 AAC 145.050. (b) The department will pay an out-of-state direct-entry midwife in accordance with 7 AAC 145.025. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 145.140. Payment for EPSDT services. (a) Except as otherwise provided in this section, the department will pay a provider in accordance with 7 AAC 145.020 for providing initial and subsequent periodic medical screening, evaluation, diagnosis, and management of a recipient under 7 AAC 110.200, not to exceed 100 percent of the rate determined under 7 AAC 145.050, even if the provider rendering the service is normally paid at a different rate for non-EPSDT services. (b) Except as provided under (c) of this section, for any dental, vision, or hearing screening or for a medically necessary treatment or required service provided in response to an EPSDT screening, the department will pay a provider in accordance with the rate established in 7 AAC 105 - 7 AAC 160 for that service and for that type of provider. (c) If an EPSDT service is provided by a tribal health program, the department will pay for that service at the applicable Indian Health Service encounter rate adopted by reference in 7 AAC 160.900. (d) If an EPSDT service is provided by a federally qualified health clinic or rural


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health clinic, the department will pay for that service at the rate determined under 7 AAC 145.700. (e) If an EPSDT service is provided by a community health aide or community health practitioner described in 7 AAC 155.020 and employed by a tribal health program, or by a public health nurse employed by a tribal health program, the department will pay for that service in accordance with (a) of this section. (f) The department will pay the United States Internal Revenue Service optional standard mileage rate for medical purposes, adopted by reference in 7 AAC 160.900, for use of a private vehicle driven for medical purposes as described in 7 AAC 110.210(d)(3). (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 145.150. Family planning services payment rates. (a) The department will pay for family planning services in accordance with 7 AAC 145.020 from a provider described in 7 AAC 110.230, not to exceed 85 percent of the amount determined under 7 AAC 145.050. (b) The department will pay for laboratory services in accordance with the payment methodology identified in 7 AAC 145.460. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 145.160. Imaging services payment rates. (a) The department will pay an in-state provider of x-ray services in accordance with 7 AAC 145.020, not to exceed 100 percent of the rate established under 7 AAC 145.050. (b) The department will pay an out-of-state x-ray provider in accordance with 7 AAC 145.025. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 145.170. Nurse anesthetist payment rates. (a) The department will pay an in-state registered nurse anesthetist in accordance with 7 AAC 145.020, not to exceed 85 percent of the rate established under 7 AAC 145.050. (b) The department will pay an out-of-state registered nurse anesthetist in accordance with 7 AAC 145.025. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 145.180. Nutrition services payment rates. The department will pay an in-state provider of nutrition services in accordance with 7 AAC 145.020, not to exceed (1) $50 for the first 30 minutes of an initial assessment; (2) $25 for each 15 minutes of an initial assessment in addition to the first 30 minutes under (1) of this section; or (3) $17.50 for each 15-minute period of service following the initial assessment. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 145.200. Physician services payment rates. (a) Except as otherwise provided in this section, the department will pay an in-state physician in accordance with 7 AAC 145.020, not to exceed 100 percent of the amount determined under 7 AAC


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145.050. (b) The department will pay an out-of-state physician in accordance with 7 AAC 145.025. (c) The department will not pay separately for office medical supplies and services associated with office visits and procedures because they are included in the practice expense component of the RBRVS methodology used in 7 AAC 145.050. The department will pay for nonroutine office medical and surgical supplies in accordance with 7 AAC 145.050(h). (d) The department will pay for laboratory or pathology services provided by a physician for which a Medicare payment rate has been established in 42 C.F.R. 405.515, adopted by reference in 7 AAC 160.900, in accordance with the methodology used to determine payment for laboratory services in 7 AAC 145.460. (e) The department will pay for the administration of anesthesia billed in accordance with the American Society of Anesthesiologist's (ASA) Relative Value Guide, adopted by reference in 7 AAC 160.900, as follows: (1) for each procedure unit basic value, $42.90; (2) for each 10-minute time unit, $36. (f) The department will pay, in accordance with 7 AAC 145.020, a supervising physician, or will pay, in accordance with 7 AAC 155.010, a tribal health program, for the services of an in-state physician assistant, except that (1) the department will pay 85 percent of the rate identified in the fee schedule established under 7 AAC 145.050; (2) laboratory charges will be paid in accordance with 7 AAC 145.460; and (3) drugs will be paid in accordance with 7 AAC 145.410(c). (g) The department will pay an out-of-state supervising physician for the services of an out-of-state physician assistant in accordance with 7 AAC 145.025. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.070 AS 47.07.030 7 AAC 145.220. Physician surgical procedures payment rates. (a) The department will pay an in-state physician for surgical procedures in accordance with the physician payment rates determined under 7 AAC 145.050, subject to the following exceptions: (1) the highest-valued procedure of multiple surgeries performed on the same recipient during the same operative session or on the same day will be paid at 100 percent of the rate determined under 7 AAC 145.050, and each additional surgery at 50 percent of the rate determined under 7 AAC 145.050; (2) bilateral surgeries will be paid at the lesser of billed charges or 150 percent of the rate determined under 7 AAC 145.050; (3) co-surgeons will be paid for the same surgical procedure, if medically necessary, by increasing the payment rate determined under 7 AAC 145.050 by 25 percent and splitting the payment equally between the surgeons; (4) intra-operative procedures only billed using modifier -54 from the list of modifiers set out in Current Procedural Terminology, adopted by reference in 7 AAC


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160.900, will be paid at the lesser of billed charges or 80 percent of the rate determined under 7 AAC 145.050; (5) pre-operative services that are performed by a physician other than the surgeon, and that are billed using modifier -56 from the list of modifiers set out in Current Procedural Terminology, adopted by reference in 7 AAC 160.900, will be paid at the lesser of the billed charges or 10 percent of the rate determined under 7 AAC 145.050; (6) postoperative services that are performed by a physician other than the surgeon, and that are billed using modifier -55 from the list of modifiers set out in Current Procedural Terminology, adopted by reference in 7 AAC 160.900, will be paid at the lesser of billed charges or 10 percent of the rate determined under 7 AAC 145.050; (7) supplies associated with surgical procedures performed in a physician’s office will be paid only when a surgical procedure is approved for payment for the same date of service in the physician’s office; the department will pay the lesser of the billed charges or the rate determined under 7 AAC 145.050(h). (b) The department will pay a physician acting as a surgical assistant the lesser of billed charges or 25 percent of the rate determined under 7 AAC 145.050. The department will pay an advanced nurse practitioner acting as a surgical assistant the lesser of billed charges or 25 percent of the rates established for advanced nurse practitioners under 7 AAC 145.100. (c) The department will pay a physician for the use of a physician assistant, acting as a surgical assistant, the lesser of billed charges or at the same rate paid to an advanced nurse practitioner as described in (b) of this section. (d) The department will pay an out-of state physician for surgical procedures in accordance with 7 AAC 145.025 and this section. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 145.240. Podiatry services payment rates. (a) The department will pay an in-state podiatrist in accordance with 7 AAC 145.020, not to exceed 100 percent of the amount determined under 7 AAC 145.050. (b) The department will pay an out-of-state podiatrist in accordance with 7 AAC 145.025. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 145.250. Private-duty nursing payment rates. (a) The department will pay an in-state private-duty nurse in accordance with 7 AAC 145.020, not to exceed (1) $20 per 15 minutes of service provided by a registered nurse or advanced nurse practitioner, including a nurse midwife; or (2) $18.75 per 15 minutes of service provided by a licensed practical nurse. (b) The department will pay an out-of-state private-duty nurse in accordance with 7 AAC 145.025. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 145.260. Psychologist services payment rates. The department will pay for psychologist services in accordance with 7 AAC 145.020, not to exceed 100 percent


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of the amount determined under 7 AAC 145.050. The department will pay for neuropsychological testing in accordance with 7 AAC 145.020, not to exceed 150 percent of the amount determined under 7 AAC 145.050. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 145.265. Targeted case management payment rates. (a) Before billing the department for targeted case management services, a provider of those services shall bill the recipient’s alternate resources under 7 AAC 160.200. After it receives notification from each third party of the amount, if any, that the third party will pay, the provider of targeted case management services may seek payment from Medicaid for the remaining cost of service. (b) The department will base payment for targeted case management services on a prospective monthly encounter rate, computed with data from base year 2004, as follows: (1) using the base year’s reported units of contact for the specified service categories identified by the department, the department will determine the average annual proportion of time participating grantees spent providing case management services; (2) the department will compute the annual portion of case manager salaries and benefits attributed to case management, using the base year’s reported expenditures for each individual providing case management services, and then, using the proportion determined in (1) of this subsection, the department will compute the average portion of salaries and benefits attributed to case management versus other activities; (3) to the number reached in (2) of this subsection, the department will add the portion of other operating costs, including travel, supplies, telephone, and occupancy costs, attributed to case management; (4) to the number reached in (3) of this subsection, the department will add direct supervisory costs, computed by using the base year’s reported expenditures for each individual who provides direct supervision to case managers, and then, using the proportion determined in (1) of this subsection, computing the portion of salaries and benefits attributed to direct supervision of case managers versus other activities; (5) to the number reached in (4) of this subsection, the department will add the average indirect administrative costs of provider organizations, computed by using the base year’s reported expenditures for indirect administrative costs, and then, using the proportion determined in (1) of this subsection, computing the portion of indirect administrative costs attributed to case management versus other activities; (6) the department will divide the sum of the results reached in (2) - (5) of this subsection by the total number of statewide case managers to obtain the total annual cost per case manager; the department will determine the total number of statewide case managers by calculating the portion of direct service provider full-time equivalents dedicated to case management, using the base year’s actual reported full-time equivalents and the proportion determined in (1) of this subsection; (7) the department will divide the total annual cost per case manager, as computed in (6) of this subsection, by 12 to obtain the monthly statewide average cost per case manager; (8) using the base year’s average actual number of children served per case manager, the department will divide the monthly statewide average cost per case


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manager by the statewide average number of children served by each case manager per month; (9) the calculated rate from base-year data will be annually updated by 2.7 percent for inflation on July 1 of each year. (c) A provider of targeted case management services may only bill the encounter rate once per child per month and must keep documentation to verify that practice. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.20.070 AS 47.07.030 AS 47.20.060 AS 47.20.110 7 AAC 145.270. Telemedicine payment rates. (a) The department will pay for a service rendered by a consulting or referring provider by a telemedicine application in accordance with 7 AAC 145.020. (b) Payment to the presenting provider is limited to the rate established for brief evaluation and management of an established patient. (c) The department will pay the receiving provider in the same manner as payment is made for the same service provided through traditional mode of delivery, not to exceed 100 percent of the rate established under 7 AAC 145.050. (d) In this section, "consulting provider," "presenting provider," "referring provider," and "telemedicine" have the meanings given in 7 AAC 110.639. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 145.280. Vision examinations and services payment rates. (a) The department will pay an in-state ophthalmologist, optometrist, or optician in accordance with 7 AAC 145.020, not to exceed 100 percent of the amount determined under 7 AAC 145.050. (b) The department will pay for postoperative management services provided by an optometrist at 10 percent of the rate determined under (a) of this section. (c) The department will pay an out-of-state ophthalmologist, optometrist, or optician in accordance with 7 AAC 145.025. (d) In addition to the rate paid under (a) - (c) of this section, the department will pay a provider (1) an additional $6 to cover the cost of sending eyeglasses by insured mail if eyeglasses are dispensed by mail; (2) $80 for dispensing and fitting contact lenses; (3) $30 for dispensing and fitting eyeglasses; and (4) $10 for eyeglass frame repair. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040

Article 4. Payment Rates; Therapies and Related Services. Section 300. Occupational therapy services payment rates 310. Outpatient therapy center payment rates 320. Physical therapy services payment rates 330. Speech-language pathology services payment rates


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340. Hearing services payment rates 350. School-based services payment rates 7 AAC 145.300. Occupational therapy services payment rates. (a) The department will pay an in-state occupational therapist in accordance with 7 AAC 145.020, not to exceed 85 percent of the rate determined under 7 AAC 145.050. (b) The department will pay an outpatient occupational therapy program operated by a tribal health program in accordance with 7 AAC 155.010. (c) The department will pay an out-of-state occupational therapist for services in accordance with 7 AAC 145.025. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 145.310. Outpatient therapy center payment rates. (a) The department will pay for outpatient therapy center services provided in state in accordance with 7 AAC 145.020, not to exceed 85 percent of the amount determined under 7 AAC 145.050. (b) The department will pay an out-of-state outpatient therapy center in accordance with 7 AAC 145.025. (c) The department will pay an out-of-state outpatient therapy center in accordance with 7 AAC 145.025 for the services of an occupational therapy assistant, physical therapy assistant, or speech-language therapist assistant. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 145.320. Physical therapy services payment rates. (a) The department will pay an in-state physical therapist in accordance with 7 AAC 145.020, not to exceed 85 percent of the rate determined under 7 AAC 145.050. (b) The department will pay an outpatient physical therapy program operated by a tribal health program in accordance with 7 AAC 155.010. (c) The department will pay an out-of-state physical therapist for services in accordance with 7 AAC 145.025. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 145.330. Speech-language pathology services payment rates. (a) The department will pay an in-state speech-language pathologist in accordance with 7 AAC 145.020, not to exceed 85 percent of the rate determined under 7 AAC 145.050. (b) The department will pay an outpatient speech-language therapy program operated by a tribal health program in accordance with 7 AAC 155.010. (c) The department will pay an out-of-state speech-language pathologist for services in accordance with 7 AAC 145.025. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 145.340. Hearing services payment rates. (a) Subject to the limitations in 7 AAC 115.530, and this section, the department will pay an in-state audiologist for audiology services (1) in accordance with 7 AAC 145.020, not to exceed 85 percent of the


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rate determined under 7 AAC 145.050; and (2) in accordance with the HCPC Fee Schedule for Audiology Services table, adopted by reference in 7 AAC 160.900. (b) Subject to the limitations in 7 AAC 115.530 and this section, the department will pay an in-state hearing aid dealer for hearing aid dealer services in accordance with the HCPC Fee Schedule for Hearing Aid Dealer Services table, adopted by reference in 7 AAC 160.900. (c) Subject to the limitations in 7 AAC 115.530 and this section, the department will pay an out-of-state audiologist or hearing aid dealer in accordance with 7 AAC 145.025. (d) The department will pay for the rental of hearing equipment and accessories at a rate not to exceed 10 percent of the purchase price per month for a maximum of 10 months. The department will not pay for a rental beyond the purchase price of the hearing equipment. (e) Subject to the limitations in 7 AAC 115.530 and this section, the department will pay for monaural and binaural hearing aids billed at the following rates and using the following codes from the Healthcare Common Procedure Coding System (HCPCS), adopted by reference in 7 AAC 160.900: (1) code V5050 for any type of monaural hearing aid in the ear, $1,500; (2) code V5060 for any type of monaural hearing aid behind the ear, $1,500; (3) code V5130 for any type of binaural hearing aid in the ear, $3,000; (4) code V5140 for any type of binaural hearing aid behind the ear, $3,000. (f) If an item or service provided to a recipient is not included in a fee schedule described in (a)(2) or (b) of this section, the department will pay an audiologist or hearing aid dealer for that item or service at 80 percent of billed charges in this state for the first nine billings for the same item or service. Thereafter, the payment rate will be established based on the 50th percentile of the first 10 billings. The department will add a new payment rate to the fee schedule each time the department receives 10 billings for that item or service not already on the schedule. To be paid under this subsection, a billing must reflect a charge that complies with the applicable standards in 7 AAC 105.120. (g) The department will not pay more than the following amounts for the following services: (1) manufacturer’s warranty deductible fee, $300 per hearing aid; (2) postage or delivery costs from an audiologist or hearing aid dealer to a recipient, $30; payment under this paragraph includes payment for a return receipt postal fee when requested at the time of mailing, but does not include payment for postal insurance; (3) postage or delivery costs from a manufacturer to an audiologist or hearing aid dealer following the manufacturer’s repair of a hearing item, $30. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040


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7 AAC 145.350. School-based services payment rates. (a) The department will pay for school-based services in accordance with 7 AAC 145.020, not to exceed 85 percent of the rate established under 7 AAC 145.050. For school-based services for which a rate is not established under 7 AAC 145.050, the department will pay for those services in accordance with the CPT Fee Schedule for School-Based Services table and the HCPC and ABC Fee Schedule for School-Based Services table, adopted by reference in 7 AAC 160.900. (b) In this section, "school-based services" has the meaning given 7 AAC 115.600(h). (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040

Article 5. Payment Rates; Prescription Drugs and Medical Supplies; Durable Medical Equipment; Transportation; Laboratory Services.

Section 400. Prescription drug payment rate 410. Dispensing fee 420. Durable medical equipment, supplies, and respiratory therapy payment rates 440. Transportation and accommodation services payment rates 460. Laboratory services payment 7 AAC 145.400. Prescription drug payment rate. (a) In addition to complying with the requirements of 7 AAC 105.220, and before submitting a claim for payment from the department, a pharmacy provider shall bill any third-party prescription drug plan in which the recipient is enrolled and that is in effect on the date of service. After the pharmacy provider receives notification from the third-party prescription drug plan of the amount, if any, that the third-party prescription drug plan will pay, the pharmacy provider may submit a claim for payment from the department for the remaining cost of service. The department will pay the pharmacy provider the difference between the payment by the third-party prescription drug plan and the department-calculated allowable payment, minus any recipient cost-sharing amounts imposed under AS 47.07.042 by the department. The department will consider the payment to be payment in full. The department will provide an exemption to a limit established under 7 AAC 120.130 for a therapeutic drug class, if the third-party prescription drug plan has a different limit for the therapeutic drug class. (b) The department will pay the provider for reasonable and necessary postage or freight costs incurred in the delivery of the prescription from the dispensing pharmacy to the recipient. (c) The payment for multiple-source drugs for which CMS has established a specific upper limit amount in accordance with 42 C.F.R. 447.514, adopted by reference in 7 AAC 160.900, is the lesser of the amount billed or that upper limit, plus the dispensing fee calculated under 7 AAC 145.410(a). (d) The payment for drugs other than those described in (c) and (h) of this section, and for brand names of multiple-source drugs specified by the prescriber in accordance with 42 C.F.R. 447.512, adopted by reference in 7 AAC 160.900, is the dispensing fee calculated under 7 AAC 145.410(a) plus the estimated acquisition cost of that drug. The estimated acquisition cost is the average wholesale price accepted weekly


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by the department from the American Druggist Blue Book, less five percent of that amount. However, the provider may not charge the department in excess of the amount applicable to a specific drug under 7 AAC 145.020 plus the dispensing fee calculated under 7 AAC 145.410(a). If a facility is a covered entity and receives its drugs as described in 42 U.S.C. 256b, the facility may not charge Medicaid more than its actual acquisition cost, a freight charge of five percent, and a dispensing fee calculated under 7 AAC 145.410(a). (e) The payment for compounding prescriptions is the sum of the costs of each of the ingredients as limited under (c) or (d) of this section, plus the dispensing fee calculated under 7 AAC 145.410(a), plus an additional compounding rate of $5.75 for each 15 minutes or portion of 15 minutes that is reasonably required to compound the prescription. (f) Payment to an out-of-state provider of drugs will be made at the Medicaid payment rate in jurisdiction in which the provider resides. Payment will be made to a provider in Canada at the lesser of the normal charge to a walk-in, cash-paying customer or the lowest total payment made for the same drug to a provider in this state. (g) A provider that dispenses drugs in unit doses to a recipient in a nursing home or other long-term care facility will receive the highest dispensing fee paid in the state under 7 AAC 145.410 for each unit dose prescription, refill, or dosage change. Unused medications must be returned to the pharmacy and the claim shall be adjusted. For purposes of this subsection, "unit dose" means a quantity of a drug that the provider re-packages into single-dosage packing. (h) A provider preparing and dispensing pharmaceuticals that are commonly described as home infusion therapy will be paid at the estimated acquisition cost of the drug as established under (d) of this section, plus the highest dispensing fee paid in the state under 7 AAC 145.410, plus a preparation fee of $10 for each 15 minutes or portion of 15 minutes that is reasonably required to prepare these drugs in a sterile or protective environment for patients in a long-term care facility and at the estimated acquisition cost without a dispensing fee or preparation fee for patients not in a long-term care facility. For purposes of this subsection, "home infusion therapy" means drugs that require the use of a laminar flow hood or clean room for the protection of either the product or preparing personnel, and include cancer chemotherapy drugs, intravenous antibiotics, and hyperalimentation drugs. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 Editor’s note: The American Druggist Blue Book is a service subscribed to by the department that provides weekly updated comprehensive electronic data on available drugs, drug classifications, national drug code (NDC) numbers, and wholesale pricing. To see how this information is used, an individual must make arrangements for an in-person visit by contacting the office of the Department of Health and Social Services, Division of Health Care Services, 4501 Business Park Boulevard, Suite 24, Anchorage, Alaska 99503-7167. 7 AAC 145.410. Dispensing fee. (a) The department will establish the dispensing fee based on the result of surveys of the costs of dispensing prescriptions for pharmacies in the state. Except as otherwise provided in this section, for each pharmacy the dispensing fee will be determined using the following formula: (1) $23,192 is added to the number that results from multiplying the total


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number of all prescriptions filled by that pharmacy in the previous calendar year by 5.070; (2) to the number arrived at under (1) of this subsection is added the result of multiplying the total number of Medicaid prescriptions filled by that pharmacy in the previous calendar year by 12.44; (3) from the number arrived at under (2) of this subsection is subtracted the result of multiplying the total floor space volume of that pharmacy, expressed in square feet, by 2.103; (4) the number arrived at under (3) of this subsection is then divided by the total number of all prescriptions filled by that pharmacy in the previous calendar year; (5) $0.73 is then added to the number arrived at under (4) of this subsection. (b) The department will not pay less than $3.45 as a dispensing fee, or more than the 90th percentile of all dispensing fees determined under the formula set out in (a) of this section. A newly established pharmacy that does not have the information available to establish a fee will be assigned the statewide average fee until that pharmacy can provide 12 months of prescription data to the department. (c) Upon request by the department, a pharmacy shall produce business records and related information relevant to the cost of drugs and the cost of dispensing. If a pharmacy does not provide dispensing fee data as requested by the department, the department may either pay that pharmacy the minimum dispensing fee established in (a) and (b) of this section or sanction the pharmacy as provided under 7 AAC 105.400 - 7 AAC 105.490. (d) Notwithstanding the provisions of 7 AAC 145.400(b) - (e) and (a) - (c) of this section, payment will be made to a dispensing provider for the estimated acquisition cost of a drug. A dispensing fee will not be included, except that a dispensing provider located over 45 miles from a retail pharmacy that is not a covered entity under 42 U.S.C. 256b may receive a dispensing fee of $5.73. (e) In addition to dispensing fees paid under (a) and (b) of this section for tobacco cessation medication, the department will pay for tobacco cessation medication therapy management that meets the requirements of 7 AAC 120.110(b) at the rate paid to an advanced nurse practitioner for services assigned code 99406 in the Current Procedural Terminology, Professional Edition, adopted by reference in 7 AAC 160.900. (f) In addition to dispensing fees paid under (a) and (b) of this section for vaccines, the department will pay for medication therapy management for vaccine administration that meets the requirements of 7 AAC 120.110(c) at a rate of $6 per vaccine administration. (g) The department will pay a provider for packaging prescription medications into a mediset in accordance with the requirements of 7 AAC 120.110(d) at the rate determined under (a) and (b) of this section. (h) In addition to a dispensing fee under (a) and (b) of this section, the department will pay a clozapine medication therapy management fee of $15 no more than once every 30 days. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040


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7 AAC 145.420. Durable medical equipment, supplies, and respiratory therapy payment rates. (a) The department will pay a durable medical equipment or prosthetic and orthotics provider in accordance with 7 AAC 145.020. (b) The department will pay a provider for durable medical equipment, medical supplies, prosthetics, orthotics, and noncustomized-fabricated orthotics for which a price has been issued by CMS, based on 100 percent of the DMEPOS Fee Schedule established by CMS for these items in this state and adopted by reference in 7 AAC 160.900. (c) The department will pay a provider for durable medical equipment, medical supplies, prosthetics, orthotics, and noncustomized-fabricated orthotics, for which CMS has not issued a price as described in (b) of this section, at 80 percent of billed charges from enrolled providers in this state for the first nine billings that reflect a charge for an item not already on the schedule established under this subsection. Thereafter, the fee will be established based on the 50th percentile of the first 10 billings. The department will add new fees to the payment schedule under this subsection each time the department receives 10 billings for an item not already on the schedule. To be paid under this subsection, a billing must reflect a charge that complies with the applicable standards in 7 AAC 145.020. (d) The department will pay separately for labor and repair parts for damaged durable medical equipment, medical supplies, prosthetics, and orthotics with the following limitations: (1) the department will not pay more than $20 for each 15 minutes of labor costs; (2) the billing for a repair part must reflect a charge that complies with the applicable standards in 7 AAC 145.020; (3) labor and repair parts for the item must be documented as necessary; documentation must include

(A) a statement signed by the recipient or the recipient’s authorized representative that describes the cause for and nature of the repair; (B) a description of the item being repaired and its serial number, if available; (C) the beginning and end dates of warranty coverage, if available; and (D) documentation for labor charges that includes the amount of time spent on the repair, rounded up to the nearest quarter hour, and the hourly rate charged for the repair;

(4) the department will not pay for labor and repair parts if the item is covered under a manufacturer’s or supplier’s warranty, or if the labor or parts are necessary to repair an item that needs repair because of a manufacturer’s defect; (5) payment will not be made for labor and repair parts for a rented item; the provider shall ensure that a rented item functions as intended after the provider repairs or replaces the item. (e) The department will not pay a provider more than the average wholesale price accepted monthly by the department from the American Druggist Blue Book, plus 10 percent of that amount, for the following items: (1) skin sealants; (2) skin protectants;


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(3) skin moisturizers; (4) skin ointments; (5) skin cleansers; (6) skin sanitizers. (f) The department will pay a provider based on the HCPC Fee Schedule for Incontinence Supplies table, adopted by reference in 7 AAC 160.900, for the following incontinence supplies: (1) garments; (2) liners; (3) under pads; (4) nonsterile gloves; (5) diaper wipes; (6) disposable washcloths. (g) For a rental period that is 30 days or more, the department will pay for rented durable medical equipment at a monthly rental rate of 10 percent of the allowed purchase price under this section. (h) For a rental period that is less than 30 days, the department will pay for rented durable medical equipment at a monthly rental rate of 150 percent of the monthly fee in (g) of this section, divided by the number of days in the month, times the number of days in the rental period. Payment may not exceed the monthly rate. (i) The department will pay a durable medical equipment provider a maximum of $75 per hour for each assessment provided to a ventilator-dependent recipient in accordance with 7 AAC 120.235(b). (j) The department will pay a provider for home infusion therapy services as follows: (1) for home infusion and specialty drug administration, the rate described in 7 AAC 145.100 per visit; (2) for home infusion administrative services, professional pharmacy services, care coordination, and necessary supplies and equipment, a per diem amount as follows:

(A) a percentage of the maximum allowed amount under (B) and (C) of this paragraph that is

(i) 100 percent for the first administered therapy; (ii) 80 percent for the second concurrently administered therapy; and (iii) 75 percent for the third and each subsequent concurrently administered therapy;

(B) the maximum allowed amount in CPT Fee Schedule for Home Infusion Therapy Services table and HCPC Fee Schedule for Home Infusion Therapy Services table, adopted by reference in 7 AAC 160.900; (C) for services not listed on the fee schedule adopted by reference in (B) of this paragraph, a maximum allowed amount that the department will establish using the method described in (c) of this section;

(3) for drugs covered under 7 AAC 120.110 and used in home infusion therapy, the payment rate determined under 7 AAC 145.400; a provider may not include compounding and dispensing fees paid under (1) of this subsection on the claim for


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drugs, unless the drugs are dispensed to a recipient in a long term care facility. (k) In this section, "durable medical equipment," "medical supplies," and "rental period" have the meanings given in 7 AAC 120.299. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 Editor’s note: The American Druggist Blue Book is a service subscribed to by the department that provides weekly updated comprehensive electronic data on available drugs, drug classifications, national drug code (NDC) numbers, and wholesale pricing. To see how this information is used, an individual must make arrangements for an in-person visit by contacting the Department of Health and Social Services, Division of Health Care Services, 4501 Business Park Boulevard, Suite 24, Anchorage, Alaska 99503-7167. 7 AAC 145.440. Transportation and accommodation services payment rates. (a) The department will pay for transportation and accommodation services in accordance with 7 AAC 145.020, not to exceed the maximum amount identified in the Transportation/Accommodation Fee Schedule table, adopted by reference in 7 AAC 160.900. (b) The department will pay for air ambulance services under (a) of this section with the following limitations: (1) payment for mileage will be based on patient-loaded statute miles from the point of patient pick-up to the destination city; (2) the point of patient pick-up determines whether the air ambulance is paid at urban or rural rates as provided in the Transportation/Accommodation Fee Schedule table, adopted by reference in 7 AAC 160.900; (3) if a flight included multiple patients, the department will split the cost of the flight among the occupants if all patients are not Medicaid recipients; (4) if a flight includes multiple patients and all patients are Medicaid recipients, the department will pay the appropriate rate established in (a) of this section for the first recipient and a flat rate of $500 for each additional recipient; (5) if a patient dies while the air ambulance is en route to the pick-up location, the department will pay the ambulance at the base-rate, lift-off fee only. (c) The department will pay for charter air services under (a) of this section with the following limitations: (1) payment may not exceed the maximum rate that would have been payable to an air ambulance service to transport the same recipient to the same location; (2) the cost of the charter flight will be evenly divided among the number of passengers on the flight. (d) In this section, "ambulance" has the meaning given in 7 AAC 120.490. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 145.460. Laboratory services payment. (a) The department will pay for laboratory services provided in state by an independent laboratory in accordance with 7 AAC 145.020, not to exceed 100 percent of the amount determined under 7 AAC 145.050. (b) The department will pay for laboratory services provided out of state by an independent laboratory in accordance with 7 AAC 145.025, not to exceed the maximum


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amount identified in (a) of this section. (c) Routine collection of venous blood by venipuncture performed with a surgical or laboratory procedure is considered incidental to that procedure and is not paid separately. (d) The department will not pay for the handling or conveyance of a specimen for transfer from the physician’s office or from the patient in other than the physician’s office to a laboratory. These procedures are considered incidental to the other services performed for the patient. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040

Article 6. Payment Rates; Personal Care and Home Health Care. Section 500. Personal care services payment rates 510. Home health care services payment rate 7 AAC 145.500. Personal care services payment rates. The department will pay a personal care agency for providing personal care services at a rate not to exceed $22.28 an hour. This rate includes payment for all personal care and administrative services rendered, including travel and telephone expenses. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 145.510. Home health care services rate. Unless otherwise provided in 7 AAC 105 - 7 AAC 160, the department will pay at a rate of 80 percent of the provider’s charges that are billed in accordance with 7 AAC 145.020. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040

Article 7. Payment Rates; Home and Community-Based Waiver Services. Section 520. Home and community-based waiver services; nursing facility and ICF/MR level-of-

care payment rates 530. Home and community-based waiver services; nursing facility and ICF/MR level-of-

care determination of administrative and general cost rates 540. Home and community-based waiver services; residential psychiatric treatment

center level-of-care payment rates 7 AAC 145.520. Home and community-based waiver services; nursing facility and ICF/MR level-of-care payment rates. (a) The department will pay a home and community-based waiver services provider in accordance with the rates and methodologies set out in this section. (b) For care coordination services provided under 7 AAC 130.240, the department will pay for a unit of service at the lesser of the (1) amount charged by the provider to the public; or (2) the following maximum allowable amount:

(A) screening - $79.50; (B) monthly care coordination - $212; (C) plan-of-care development - $339.20.


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(c) The department will pay for specialized medical equipment and supplies provided under 7 AAC 130.305 in accordance with 7 AAC 145.420. (d) The department will pay for specialized private-duty nursing services provided under 7 AAC 130.285 in accordance with 7 AAC 145.250. (e) For environmental modification services provided under 7 AAC 130.300, the department will pay 100 percent of billed charges to a home and community-based waiver services provider. In addition, the department will pay the provider an administrative fee of two percent of the billed charges or $50, whichever is greater, if the provider (1) is certified and enrolled under 7 AAC 130.220(b)(1)(J); and (2) acts as an organized health care delivery system under 42 C.F.R. 447.10 for the purpose of overseeing the purchase of an environmental modification for a recipient. (f) For chore services provided under 7 AAC 130.245, adult day services provided under 7 AAC 130.250, day habilitation services provided under 7 AAC 130.260, residential habilitation services provided under 7 AAC 130.265, supported-employment services provided under 7 AAC 130.270, intensive active treatment services provided under 7 AAC 130.275, respite care services provided under 7 AAC 130.280, transportation services provided under 7 AAC 130.290(a), or meals services provided under 7 AAC 130.295, the department will base payment for a unit of service upon the (1) rates established in the department’s Current Waiver Services Regulatory Rates table, adopted by reference in 7 AAC 160.900; or (2) allowable direct service costs, as established under 7 AAC 145.530, for the service provided, and allowances to compensate the provider for the provider’s allowable administrative and general costs, as established under 7 AAC 145.530, associated with providing the service; however, the department will not include an allowance under this paragraph for any administrative or general costs for

(A) out-of-home daily respite care services or family-directed respite care services under 7 AAC 130.280; (B) meals services under 7 AAC 130.295; or (C) services provided by a home and community-based waiver services provider acting as an organized health care delivery system under 42 C.F.R. 447.10.

(g) In determining payment rates under (f) of this section, the department will consider only those costs identified in 7 AAC 145.530 that are anticipated to be paid or borne by the provider. In evaluating the reasonableness of a provider’s projected costs under (f) of this section and 7 AAC 145.530, the department may conduct cost comparisons for similar services or items of expense and deny any cost that appears to be excessive. (h) A provider of home and community-based waiver services in an assisted living home licensed under AS 47.32 may seek payment for a unit of service at the rate determined under (f) or (l) of this section, or at the rate determined under this subsection. A residential supported living services provider under 7 AAC 130.255 may seek payment for a unit of service either at the rate determined under (k) of this section or at the rate determined under this subsection. The department will base payment under this subsection upon the following:


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(1) for a provider that is licensed as an assisted living home for fewer than six residents, the department will use a base service rate of $46.30 per day; (2) for a provider that is licensed as an assisted living home for six or more residents and does not provide 24-hour awake staff, the department will use a base service rate of $58.34 per day; (3) for a provider that is licensed as an assisted living home for six or more residents and provides 24-hour awake staff, the department will use a base service rate of $70.39 per day; (4) the amount of payment to a provider under (1) - (3) of this subsection will be decreased by 26 percent of the base service rate per day if a recipient also receives adult day services under 7 AAC 130.250 for three or more days in a seven-day period; (5) the amount of payment to a provider under (1) - (3) of this subsection will be increased by $18.06 per day if the recipient’s needs warrant the hiring or designation of additional staff by the provider to augment the care given to the recipient; (6) a base service rate under (1) - (3) of this subsection will be adjusted to reflect regional differences in the cost of doing business, based on the region in which the provider is located; based upon the designated planning regions described in the New Funding Formula for Title III and Title V Programs table of the Alaska Commission on Aging's Alaska State Plan for Senior Services, adopted by reference in 7 AAC 160.900, the rate adjustments are as follows:

(A) for the Anchorage region - no adjustment; (B) for the southcentral region, other than Anchorage - 1.04; (C) for the southeast region - no adjustment; (D) for the interior region - 1.15; (E) for the southwest region - 1.33; (F) for the northwest region - 1.38;

(7) a service rate under (1) - (6) of this subsection will be adjusted to increase the rate by $9 per day; this increase is not subject to the regional adjustment under (6) of this subsection; (8) subject to the availability of appropriations, a service rate determined under (1) - (6) of this subsection will be adjusted by the department by, and effective at the same time as, a cost-of-living percentage increase in benefit amounts under 42 U.S.C. 1382f. (i) If a recipient has been determined eligible for Medicaid coverage under 7 AAC 100.002(d)(8)(B), the recipient’s income, exclusive of the personal needs allowance and other deductions described in 7 AAC 100.554, is a prior resource for home and community-based waiver services. Once the department has determined the recipient’s monthly liability under 7 AAC 100.554, the recipient shall pay that liability toward the cost of care for home and community-based waiver services. If a recipient is receiving residential supported living services under 7 AAC 130.255, the recipient shall pay the liability first to the recipient’s residential supported living services provider, and second to other home and community-based waiver services providers if any monthly liability remains. (j) Notwithstanding 7 AAC 145.530, the department will not approve an increase in the amount of payment per unit of service for a service whose per-unit amount of payment has been determined using the methodology in (f) or (l) of this section, except


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that for services provided on or after July 1, 2008, the department will increase the rates calculated under (f) and (l) of this section by four percent. (k) A provider of family habilitation home services and group-home habilitation services under 7 AAC 130.265 and residential supported-living services under 7 AAC 130.255 may calculate a daily rate for a service under this subsection by dividing the estimated annual cost by 342. The calculation under this subsection does not apply to any other home and community-based waiver service. (l) Except as provided in (m) and (n) of this section, a home and community-based waiver services provider who has obtained a cost-based rate under 7 AAC 145.530 must use that rate when seeking payment from the department. A home and community-based waiver services provider who has not obtained a cost-based rate under 7 AAC 145.530 may (1) obtain a cost-based rate under 7 AAC 145.530 and seek payment under (f)(2) of this section; (2) seek payment under (f)(1) of this section; or (3) seek payment based upon a rate equal to the provider’s average rate for the service during the last fiscal year. (m) Notwithstanding (l) of this section, if a home and community-based waiver services provider has expanded into an area to provide a service the provider has not previously billed the department for in the area, the department will pay the provider under this subsection based upon a rate equal to the lower of (1) the provider’s average rate for the service provided in all other areas; (2) the average rate of all other providers of the service in the area; or (3) the provider’s cost-based rate under 7 AAC 145.530. (n) Notwithstanding (l) of this section, if a home and community-based waiver services provider expands to take over an existing recipient’s plan of care, the department will pay the provider based upon the rate the department has already approved for the recipient for each service for the remainder of the recipient’s plan-of-care year, or the provider’s cost-based rate, whichever is lower. (o) Notwithstanding (j) of this section, a provider of residential supported-living services under 7 AAC 130.255 or residential habilitation services under 7 AAC 130.265 may request an increase in cost per unit of service, as a change to a recipient’s plan of care, by submitting a written request to the department along with documentation that the increase is necessary to protect the health, safety, or welfare of the recipient. An increase must be approved by the director of the division of the department that administers home and community-based waiver services. For purposes of this subsection, an increase is (1) necessary to protect the health, safety, or welfare of a recipient if without the services the recipient is likely to suffer increased isolation, medical acuity, or immediate hospitalization; and (2) not necessary to protect the health, safety, or welfare of a recipient if the increase is sought

(A) for administrative costs; for purposes of this subparagraph, administrative costs include

(i) a change in rates established under 7 AAC 145.530; (ii) employment costs, including changes in salary or benefits; and


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(iii) other business-related costs and expenses; (B) so that a recipient may change providers; (C) so that the provider may expand its services to a new location; or (D) to provide personal care services that the department has determined are no longer warranted under 7 AAC 125.010 - 7 AAC 125.199.

(p) The department will not pay more than $260 per day for respite care services under 7 AAC 130.280. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.045 7 AAC 145.530. Home and community-based waiver services; nursing facility and ICF/MR level-of-care determination of administrative and general cost rates. (a) A home and community-based waiver services provider seeking an administrative and general cost rate for services paid under 7 AAC 145.520(f)(2) must comply with the applicable requirements of this section. If a provider does not comply with those requirements, the department will calculate a payable unit rate based solely on the allowable direct service costs for the service provided. (b) The department will approve an administrative and general cost rate for a home and community-based waiver services provider at the time of initial certification under 7 AAC 130.220 and annually thereafter, at the beginning of the waiver year in which the rate is payable. When first applying for provider certification and no later than 30 days before the start of each following waiver year, a provider seeking an administrative and general cost rate shall submit to the department the following information on a form or in a format approved by the department: (1) a proposed operating budget for the provider’s next fiscal year that sets out all anticipated funding sources and amounts, including recipient contributions to room and board if applicable, and that breaks anticipated costs into the categories of allowable direct service costs, nonallowable direct service costs, allowable administrative and general costs, and nonallowable administrative and general costs; (2) a calculation of the administrative and general cost rate for the provider that is determined by dividing the provider’s total allowable administrative and general costs by the sum of the provider’s total allowable and nonallowable direct service costs and the provider’s total nonallowable administrative and general costs; however, a provider’s administrative and general cost rate may not exceed 18 percent of the sum of the provider’s total allowable and nonallowable direct service costs and the provider’s total nonallowable administrative and general costs, unless the provider provides only residential supported-living services under 7 AAC 130.255; if a provider provides only residential supported-living services under 7 AAC 130.255, that provider’s administrative and general cost rate may not exceed 25 percent of the sum of the provider’s total allowable and nonallowable direct service costs and the provider’s total nonallowable administrative and general costs. (c) Upon review of the information provided under (b) of this section and any additional information provided under this subsection, the department may ask for clarification, request additional information, or approve the provider’s administrative and general cost rate. The department will provide written notification to the provider of the final approved rate.


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(d) In this section, (1) "administrative and general costs" means those expenses that are common to the overall operation of a provider providing home and community-based waiver services and that are not directly assignable to or borne by a specific program or recipient of a home and community-based waiver service; (2) "administrative transportation costs" means costs that are not reimbursable under 7 AAC 130.290 and do not directly enable a recipient to gain access to services; (3) "allowable administrative and general costs" include

(A) board of directors’ expenses, including travel and training costs directly associated with board functions on behalf of the provider, but excluding lobbying activities; (B) administrative support costs, including the costs of

(i) personal services and associated benefits, training, and travel of the provider’s executive director and its secretarial, clerical, accounting, and other administrative staff; (ii) office equipment, including leased equipment, supplies, postage, related professional subscriptions, and associated procurement costs; (iii) facility operations, including rent, interest on capital loans, utilities, equipment, security systems, and routine maintenance; and (iv) professional dues for professional staff;

(C) contractual costs for consulting, legal, and financial accounting and auditing services; (D) public relations and community education expenses related to advertisements, brochures, newsletters, marketing, surveys, and staff and community development activities; and (E) insurance expenses, including professional liability, automobile and facility coverage, and bonding;

(4) "allowable direct service costs" include (A) personal service costs, including salaries, annualized hourly wages, contract labor payments, and stipends paid for direct care staff and associated benefit costs, including payroll taxes and insurance; whatever form these costs take, they must be commensurate with compensation paid for similar staff positions performing similar duties for the provider; (B) travel costs for recipients and providers including transportation, per diem, and meal allowances; these costs may not be charged at rates that exceed those allowed under the general government bargaining unit employees’ agreement with the state in effect for July 1, 2000 - June 30, 2003; for purposes of this subparagraph, the travel cost rates set out in article 30, sections 30.01 - 30.04 and 30.07 - 30.08 of the general government bargaining unit employees’ agreement with the state for July 1, 2000 – June 30, 2003 are adopted by reference; (C) the costs of items or services purchased for recipients that are necessary to carry out their approved plans of care; (D) room and board costs for


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(i) respite care services provided under 7 AAC 130.280 in a nursing facility, acute care hospital, intermediate care facility for the mentally retarded or persons with related conditions (ICF/MR), assisted living home licensed under AS 47.32, or foster home licensed under AS 47.32; or (ii) meals that are provided as part of a unit of adult day services provided under 7 AAC 130.250, as part of a unit of day habilitation services provided under 7 AAC 130.260, or in a unit of meals service provided under 7 AAC 130.295; and

(E) administrative transportation costs in an assisted living home licensed under AS 47.32, as follows:

(i) for an assisted living home serving 1 - 10 recipients, costs not to exceed $1,000 per recipient per year; (ii) for an assisted living home serving 11 or more recipients, actual administrative transportation costs if the assisted living home provides the department documentation of those costs;

(5) "contingency funds" means funds that have been accumulated but not expended; (6) "nonallowable administrative and general costs" include

(A) lobbying expenses; (B) fund raising expenses; (C) contingency funds; (D) fines, penalties, and bad debts; (E) contributions or donations; (F) entertainment expenses, including meals, banquets, gratuities, and decorations; (G) organization dues that are based on a percentage of grant award amounts; and (H) other costs not allowed under requirements or special conditions related to other state grant awards to the provider;

(7) "nonallowable direct service costs" include (A) items or services purchased for recipients that are not necessary to carry out their approved plans of care; and (B) room and board costs other than those described in (1)(D) of this subsection;

(8) "waiver year" means the year in effect in a multiple-year waiver period approved under 42 U.S.C. 1396n(c) that begins July 1 and ends June 30. (e) Notwithstanding the requirements of this section, a home and community-based waiver services provider may choose to obtain an indirect cost rate agreed upon by the federal government and the home and community-based waiver services provider. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.045 AS 47.07.030 7 AAC 145.540. Home and community-based waiver services; residential psychiatric treatment center level-of-care payment rates. (a) The department will


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pay for FASD/SED plan-of-care development and coordination services provided under 7 AAC 130.130, including supervising the delivery of services under 7 AAC 130.140, at the lesser of the billed charges or $65 per hour per recipient. (b) The department will pay for training and consultation services provided under 7 AAC 130.135 at the lesser of the billed charges or, (1) for paraprofessional training and consultation services, $45 per hour per recipient up to a maximum of eight hours per month per recipient; and (2) for professional training and consultation services, $65 per hour per recipient up to a maximum of five hours per month per recipient. (c) The department will pay for training and intervention mentor services provided under 7 AAC 130.140 at the lesser of the billed charges or $65 per hour. (d) The department will pay for day habilitation services provided under 7 AAC 130.145 at the lesser of the billed charges or $65 per hour. (e) The department will pay for residential habilitation services provided under 7 AAC 130.150 at the lesser of the billed charges or $100 per day per recipient. (f) The department will pay the actual cost of community transition services provided under 7 AAC 130.155 up to a maximum of $2,075 per recipient per continuous 12-month period, beginning with the date the recipient is enrolled under 7 AAC 130.110. A provider may include no more than $75 per recipient for administrative costs when determining the actual cost of community transition services. (g) The department will pay for supported-employment development services provided under 7 AAC 130.160 at the lesser of billed charges or $45 per hour per recipient. (h) The department will pay for supported-employment ongoing services provided under 7 AAC 130.160 at the lesser of the billed charges or $65 per hour. (i) The department will pay a provider of respite care services provided under 7 AAC 130.165 the lesser of the billed charges or (1) $20.76 per hour, not to exceed $265 in a 24-hour period or 520 hours per year; or (2) if providing daily respite care services for more than 12 hours in a 24-hour period, $265 in a 24-hour period, not to exceed 24 days per year. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.045 AS 47.07.030

Article 8. Payment Rates; Behavioral Health Services. Section 580. Behavioral health services payment rates 7 AAC 145.580. Behavioral health services payment rates. The department will pay a provider for the following mental health services provided under 7 AAC 105 - 7 AAC 160 at the following rates: (1) for individual psychotherapy, the lesser of the provider’s lowest charge to the general public or $80 per hour; (2) for family psychotherapy, the lesser of the provider’s lowest charge to the general public or $80 per hour;


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(3) for group psychotherapy, the lesser of the provider’s lowest charge to the general public or $45 per session for each recipient eligible for payments under 7 AAC 150 - 7 AAC 160; (4) for an intake assessment, $85 per hour, for a maximum of three hours per assessment; (5) for a psychiatric assessment, $230 per assessment, not to exceed four assessments in any calendar year; (6) for psychological testing and evaluation, the lesser of the provider’s lowest charge to the general public or $85 per hour; (7) for services provided out of state, payment to providers at the Medicaid rate in the state where the service was provided; (8) for crisis intervention, $75 per hour for a maximum of two hours per day; (9) for group skill development services, $30 per hour per recipient; (10) for pharmacologic management, $75 per visit. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040

Article 9. Payment Rates; Facility and Facility-Based Services. Section 600. Hospital payment rates 610. Inpatient psychiatric hospital payment rates 620. Residential psychiatric treatment center payment rates 630. Ambulatory surgical center payment rates 640. Nursing facility payment rates 650. ICF and SNF all-inclusive rates 660. ICF/MR all-inclusive rate 670. Recipient cost-of-care contribution 690. Hospice care payment rates 7 AAC 145.600. Hospital payment rates. (a) The department will pay an in-state general acute care hospital for services rendered in the state at the rate determined in accordance with 7 AAC 150. (b) The department will pay an out-of-state hospital at the Medicaid rate used by the jurisdiction where the hospital is located, or if no Medicaid rate has been established, the Medicare rate for the hospital, or if no Medicare rate has been established, the Blue Cross rate. (c) Except in emergency situations, payment will not be made for out-of-state hospital services that are available in this state unless the out-of-state hospitalization has been specifically approved by the department. (d) The department may negotiate a hospital-specific payment agreement for unique expertise or specialized services not available in this state. Factors that the department will consider in making the decision to negotiate a facility-specific payment agreement under this subsection include (1) the medical necessity for the out-of-state hospital service; (2) whether the service is widely available out of state or available only


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from a limited number of out-of-state providers; (3) the professional standing of the facility within the health care services community for the unique expertise or specialized service; (4) any extreme circumstance concerning the medical needs of the patient; and (5) whether a facility-specific payment agreement is necessary to ensure access to appropriate medical services that otherwise would not be available. (e) The hospital-specific payment agreement under (d) of this section is not available for general services offered by the hospital and is limited to the specific services set out in the payment agreement. General services offered by the hospital and not associated with unique expertise or specialized services in the payment agreement will be paid under (b) of this section. (f) The hospital-specific payment agreement under (d) of this section will be for a specific period of time not to exceed two years. (g) Except as provided in this section, the department will process claims for out-of-state hospital services in accordance with the claim process established for hospitals in this state under 7 AAC 140.300 - 7 AAC 140.325. (h) Charges to the department for out-of-state inpatient and outpatient hospital services may not exceed the hospital’s usual and customary charges for the same service to the general public. (i) The department will pay for the day of admission but not for the day of discharge, transfer to another facility, or death. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 145.610. Inpatient psychiatric hospital payment rates. (a) Except as provided in (c) of this section, the department will pay for inpatient psychiatric services provided in accordance with 7 AAC 140.350 - 7 AAC 140.365 at the daily rate determined under 7 AAC 150. (b) The department will pay for the day of admission but not for the day of discharge, transfer to another facility, or death. (c) Except for costs related to a physical examination at the time of admission to the inpatient psychiatric hospital, the department will pay separately for the covered services provided in the hospital by a physician or an advanced nurse practitioner. The department will pay separately for other necessary covered medical or dental services not related to the inpatient psychiatric admission that are provided in accordance with 7 AAC 43 and 7 AAC 105 - 7 AAC 160. The department will not pay separately for drugs provided in an inpatient psychiatric hospital, because drugs are included in determining the all-inclusive daily payment rate under 7 AAC 150. (d) The department will pay in accordance with 7 AAC 105.120 for inpatient psychiatric treatment center services provided outside the state. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 145.620. Residential psychiatric treatment center payment rate. (a) Except as provided in (b) of this section, the department will pay for residential psychiatric treatment center services provided in accordance with 7 AAC 140.400 -


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7 AAC 140.415 at the daily rate determined under (c) of this section. (b) The department will pay a provider separately for (1) psychological testing and evaluation services if those services are not available through the residential psychiatric treatment center; (2) prescription drugs and other covered services provided directly by a physician or advanced nurse practitioner; or (3) other necessary covered medical or dental services not related to the residential psychiatric treatment center admission. (c) Based on periodic review of appropriate cost studies, the department will determine a daily rate to be paid for residential psychiatric treatment center services that is sufficient to enlist enough providers so that residential psychiatric treatment center services are available to Medicaid recipients at least to the extent that those services are available to the general population. (d) The department will periodically determine the daily rate, in accordance with (c) of this section, and will notify each enrolled residential psychiatric treatment center provider of any change made in the amount of the daily rate. (e) Notwithstanding (c) and (d) of this section, the department will pay a flat rate of $211 per day to a residential psychiatric treatment center for each therapeutic transition day authorized for a recipient under 7 AAC 140.405(g). In this subsection, "therapeutic transition day" means a calendar day related to a hospitalization in a residential psychiatric treatment center that is authorized by the department for payment for services for a recipient under 21 years of age who has been stabilized and is therefore ready for transition or discharge. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 145.630. Ambulatory surgical center payment rates. (a) The department will pay for services rendered in an ambulatory surgical center at the rate determined in accordance with 7 AAC 150. The department shall establish payment rates for each group code as assigned by the Ambulatory Surgical Center (ACS) Approved HCPCS Codes and Payment Rates spreadsheet, adopted by reference in 7 AAC 160.900. The department will pay the highest valued procedure of multiple procedures at 100 percent of the procedure’s group rate and all additional procedures will be paid at 50 percent of the procedure group rate. (b) A payment made under (a) of this section covers all operative functions attendant to medically necessary surgery performed at the clinic by a private physician or dentist, including admitting and laboratory tests, recipient history and examination, operating room staffing and attendants, recovery room care, and discharge. The payment includes all supplies related to the surgical care of the recipient while in the clinic. The payment excludes the physician’s fee, radiologist’s fee, and anesthesiologist’s fee. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.070 AS 47.07.030 7 AAC 145.640. Nursing facility payment rates. (a) Except as otherwise provided in this section, the department will pay for services rendered by an intermediate care facility (ICF) or skilled nursing facility (SNF) at the all-inclusive rate determined in


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accordance with 7 AAC 150, less the cost-of-care liability determined under 7 AAC 100.554. (b) Partial payment may be made to a nursing facility upon request. Partial payment may be made monthly in an amount not to exceed 80 percent of the average monthly billing for the previous state fiscal quarter. (c) A recipient’s income is a prior resource. If a recipient remains in a nursing facility for a period of less than a full month, the recipient’s income for the month, after subtracting all allowable deductions, must be divided by the number of days in the month and that daily amount applied to those days that the recipient was in the nursing facility. (d) The department will pay an out-of-state nursing facility at the Medicaid rate used by the jurisdiction where the facility is located. (e) Payment by the department is payment in full for those services authorized under Medicaid. If the nursing facility obtains from another source any additional payment for the care provided to a recipient for services that have been paid for by Medicaid, the facility shall refund or credit the additional payments to the department. (f) A nursing facility may not submit a claim for payment that exceeds the rate charged to a private client for any item or service charged by the facility. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.070 AS 47.07.030 7 AAC 145.650. ICF and SNF all-inclusive rates. (a) The rate established for an intermediate care facility or a skilled nursing facility includes all services, supplies, and equipment required for complete care, except as otherwise provided in this section. (b) The following services are included in the ICF or SNF all-inclusive rate and will not be paid for separately: (1) rehabilitative nursing care, including service of restorative aides and nurses, as part of nursing and supportive care services; (2) nonprescription drugs; (3) direct physical or occupational therapy services to an individual recipient, prescribed by a physician; (4) consultation, training, and other nondirect recipient care services by a physical therapist, physical therapy assistant, occupational therapist, or occupational therapy assistant, whether or not the therapist or assistant is an employee of the facility; (5) periodic oxygen, if that is all that is required by the recipient; (6) all transportation in a facility's vehicle and related to the recipient’s care and recreation; (7) an annual physical examination for a recipient in a long-term care facility. (c) The following services are not included in the ICF or SNF all-inclusive rate: (1) health care services by providers not employed by the facility or on contract with the facility to provide services; (2) personal incidental items authorized for payment from the recipient’s personal incidental allowance or cash reserve; (3) nonemergency continuous heavy use of oxygen as described in 7 AAC 140.580(b); if given prior authorization by the department, the department will pay the


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facility the facility’s cost of the oxygen; (4) legend drugs and biologicals; (5) medical services, including x-ray and laboratory procedures, provided in or out of a facility by a physician, hospital, or other provider; (6) essential transportation of a recipient to and from a source of medical care; the department will pay the carrier directly for that essential transportation; (7) transportation for nonmedical reasons in a vehicle other than the facility’s vehicle. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.070 AS 47.07.030 7 AAC 145.660. ICF/MR all-inclusive rate. (a) The rate established for an intermediate care facility for the mentally retarded (ICF/MR) includes all services, supplies, and equipment required for complete care, except as otherwise provided in this section. (b) The following services are included in the ICF/MR all-inclusive rate and will not be paid for separately: (1) resident living staff, dental services, training and habilitation services, medical services, nursing services, pharmacy services, physical and occupational therapy services, psychological services, recreational services, social services, and speech pathology and audiology services, as prescribed in 42 C.F.R. 442.300 - 442.516, adopted by reference in 7 AAC 160.900; (2) nonprescription drugs; (3) periodic oxygen, if that is all that is required by the recipient; (4) all transportation in a facility’s vehicle and related to the recipient’s care and recreation; (5) an annual physical examination for a recipient in a long-term care facility. (c) The following services are not included in the ICF/MR all-inclusive rate: (1) services provided out of the facility by a physician, hospital, or other provider, other than services listed in (b)(1) of this section; (2) nonemergency, continuous heavy use of oxygen described in 7 AAC 140.615(a); if given prior authorization by the department, the department will pay the facility the facility’s cost of the oxygen; (3) legend drugs and biologicals; (4) essential transportation for residents to and from a source of medical care; the department will pay the carrier directly for that essential transportation; (5) transportation for nonmedical reasons in a vehicle other than the facility’s vehicle. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.070 AS 47.07.030 7 AAC 145.670. Recipient cost-of-care liability. (a) The payment determined under 7 AAC 145.650 and 7 AAC 145.660 will be reduced by the amount of the recipient cost-of-care liability determined by the department in accordance with 7 AAC 100.554. (b) The facility is responsible for collecting from the recipient the amount of the


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recipient’s cost-of-care liability. The department will not increase its payment to the facility because the recipient fails to pay the recipient cost-of-care amount. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.070 AS 47.07.030 7 AAC 145.690. Hospice care payment rates. (a) The department will pay an in-state hospice at the Medicaid rates established under 42 C.F.R. 418.306, adopted by reference in 7 AAC 160.900, for routine home care, continuous home care, inpatient respite care, and general inpatient care. The hospice shall pay a participating facility for general inpatient and inpatient respite care. (b) The department will pay an in-state hospice for the cost of room and board for care provided to a recipient in a nursing facility or intermediate care facility for the mentally retarded if the hospice has a written agreement under which the hospice takes full responsibility for the professional management of the recipient’s hospice care and the nursing facility or facility agrees to provide room and board to the recipient. The room and board provided by the facility must, at a minimum, include personal care services, administration of medication, maintenance of the recipient’s room, and supervision and assistance in the use of durable medical equipment and prescribed therapies. (c) In addition to the payment described in (a) of this section, the department will pay for (1) room and board, as described under (b) of this section, at the rate of 95 percent of the daily rate established under 7 AAC 150; and (2) physician services rendered by the hospice medical director as a licensed physician or by the licensed physician member of the interdisciplinary group, at the rate determined under 7 AAC 145.200(a) - (c). (d) The department will not pay a hospice for inpatient days, including respite care, that exceeds 20 percent of the aggregate number of days of hospice care provided to all recipients during the immediately preceding 12-month period that began after October 31 and ended before November 1, excluding from the total number of recipient any recipient who has acquired immunodeficiency syndrome (AIDS). The hospice must refund to the department the excess payments less the routine home care rate for each day over the 20 percent of the total hospice days billed. (e) In this section, "continuous home care,""general inpatient care,""inpatient respite care,""interdisciplinary group," and "routine home care" have the meanings given in 7 AAC 140.289. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 Editor’s note: A copy of the rate schedule described in 7 AAC 145.690(a) may be obtained by contacting the Department of Health and Social Services, division of health care services, P.O. Box 110660, Juneau, Alaska 99811-0660.

Article 10: Payment Rates; Rural Health Clinic and Federally Qualified Health Center Services.

Section 700. Health clinic payment rates


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710. Calculating total health clinic visits 720. Health clinic re-basing 730. Health clinic exceptional relief 7 AAC 145.700. Health clinic payment rates. (a) Except for services listed in (e) of this section, the department will determine a rural health clinic’s payment rate or a federally qualified health center's payment rate based on the health clinic’s reasonable costs. Reasonable costs must be determined by using the same methodology used under 42 U.S.C. 1395l(a)(3) and 42 C.F.R. 413.1 - 413.157. Costs must be related to furnishing medically necessary and appropriate services to Medicaid-eligible patients in accordance with 7 AAC 140.215. Costs may not include the cost of providing prescription drugs. The department will consider only costs that are related to providing Medicaid-eligible services to Medicaid-eligible patients, and will exclude other costs. A health clinic may receive payment only for services provided to a patient of the clinic by an employee or a contract worker of the clinic. The department’s payment for services provided by the health clinic will be paid to the health clinic. (b) Unless the department and a health clinic make an agreement for the department to pay the clinic at the rates calculated under (g) of this section, the department will pay the clinic in accordance with 42 U.S.C. 1396a(bb)(1) - (5), adopted by reference in 7 AAC 160.900. (c) If, consistent with the alternative payment methodology provisions of 42 U.S.C. 1396a(bb)(6), adopted by reference in 7 AAC 160.900, the department and a health clinic make an agreement for the department to pay the clinic at the rate calculated under this subsection, the department will calculate a prospective payment rate as follows: (1) base rates will be calculated prospectively,

(A) in an amount calculated on a per-visit basis and equal to 100 percent of the inflated average of the allowable costs

(i) of the health clinic of furnishing services during the health clinic’s fiscal years 1999 and 2000; and (ii) that are reasonable and related to the cost of furnishing those services; and

(B) in accordance with the following formula: (i) the clinic’s total allowable and reasonable cost of providing primary care and ambulatory services for fiscal year 1999 will be inflated by the number set out in the first quarter 1999 publication of DRI-WEFA’s Health Care Cost Review, Skilled Nursing Facility Total Market Basket, inflated to 2001; (ii) the clinic’s total allowable and reasonable cost of providing primary care and ambulatory services for fiscal year 2000 will be inflated by the number set out in the first quarter 2000 publication of DRI-WEFA’s Health Care Cost Review, Skilled Nursing Facility Total Market Basket, inflated to 2001; (iii) to obtain the base per-visit rate, the sum of the numbers calculated in (i) and (ii) of this subparagraph will be divided by the total number of visits as calculated under 7 AAC 145.710;


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(iv) the base per visit rate obtained under (iii) of this subparagraph will be adjusted to take into account any increase or decrease in the scope of services during fiscal year 2001 that the department has approved under (f) of this section;

(2) beginning with the health clinic fiscal year 2003, and for each health clinic fiscal year that follows, the payment rate as calculated in (1) of this subsection will be

(A) increased in that fiscal year by using the first quarter publication of Global Insight’s Health-Care Cost Review, Skilled Nursing Facility Total Market Basket for yearly adjustment factors applied to health clinics; and (B) adjusted for that fiscal year to take into account any change in the scope of services that the department has approved under (f) of this section, whether the change in the scope of services is proposed for that fiscal year or occurred in the preceding fiscal year;

(3) the payment rate calculated under this subsection must result in a payment to the health clinic that is equal to or greater than the amount required to be paid to the clinic under 42 U.S.C. 1396a(bb)(1) - (6), adopted by reference in 7 AAC 160.900; if the payment rate calculated under this subsection is less than that amount, the department will pay the health clinic under (b) of this section; to ensure compliance with this paragraph, the department will evaluate annually the

(A) Medicare Economic Index as required by 42 U.S.C. 1396a(bb)(3)(A), adopted by reference in 7 AAC 160.900; and (B) number set out in the first quarter publication of Global Insight’s Health-Care Cost Review, Skilled Nursing Facility Total Market Basket;

(4) the department will annually evaluate the payment rate calculated under this subsection to ensure it is within the payment limit set under 42 C.F.R. 447.300 - 447.371, adopted by reference in 7 AAC 160.900. (d) For purposes of this section, the department will consider health clinic costs to be allowable costs if they are documented costs as described in 42 C.F.R. 405.2468, adopted by reference in 7 AAC 160.900, after all adjustments, cost disallowances, and reclassifications have been made, if those costs are reasonable in amount, if they are proper and necessary for the efficient delivery of health clinic services, and if they are not disallowed under AS 47.07, 7 AAC 105 - 7 AAC 160, or applicable federal statutes or regulations. Allowable costs do not include overhead costs not directly related to health clinic services, bad debts, charity care, contractual allowances, return on equity, income taxes, or services and supplies furnished to non-Medicaid recipients for free or without regard to the recipient’s ability to pay. (e) In establishing a payment rate under this section, the department will not include services that are paid by a different payment rate methodology in 7 AAC 105 - 7 AAC 160. Services that are paid by a different payment rate methodology include (1) prescription drugs subject to the drug coverage limitations in 7 AAC 120.100 - 7 AAC 120.130 and paid in accordance with 7 AAC 145.400 - 7 AAC 145.410; and (2) labor and delivery services provided by a physician, a physician assistant, or an advanced nurse practitioner paid in accordance with 7 AAC 145.050. (f) Changes in the scope of services that are provided by a health clinic will be


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used to adjust the per-visit rate for a health clinic. These adjustments will be made upon the written notification of the provider and approval by the department. The change in scope of services must have increased or decreased a health clinic’s cost per visit by more than two and one-half percent. The change in the scope of services must be directly related to a new or terminated program or service, and may not include general increases or decreases in costs associated with programs that were already a part of an established rate. The department will examine a written request for a change in scope of services no more than 60 days after receipt to determine if the change satisfies the requirements of this subsection. The health clinic shall submit to the department a brief narrative describing the services that are to be added or deleted or that result in an increase or decrease in the scope of services. Additionally, a health clinic that proposes a change in the scope of services for future implementation must provide a one-year budget that specifies the change in the scope of services, shows the projected number of visits, and provides revenue and expense projections associated with the proposed change. If the department determines that a change in the scope of services has occurred, the per-visit rate will be adjusted. A final decision regarding the disposition of a request for a change in scope of services will be given to a clinic in writing. If the health clinic notifies the department (1) before implementing the change in the scope of services that a change will occur, any adjustment will be made to coincide with the implementation date of the change; (2) after implementing the change that an increase or decrease in the scope of services occurred, any adjustment will be made to coincide with the

(A) date of notification, for the addition of a category of service; a post-implementation request for a rate adjustment must be received no later than 45 days after the change in scope of services occurred; or (B) implementation date of the change, for the deletion of a category of service or a change in the intensity of a service.

(g) A health clinic that enrolls during or after health clinic fiscal year 2000, and that (1) submits cost data for a minimum of six months during the health clinic fiscal year 1999 and 2000 period, may request payment at a per-visit rate that is based on the submitted data; (2) does not submit cost data for a minimum of six months, will be paid a per-visit rate equal to the statewide weighted average of the total Medicaid per-visit payment rates made to health clinics; the base per-visit rate will be re-determined

(A) after Medicare cost reports for health clinic fiscal years one and two are submitted and are reviewed by the department, and will be inflated in accordance with (c) of this section, except that the first two fiscal years of data that the clinic has available will be substituted for fiscal years 1999 and 2000; and (B) to allow payments for each succeeding health clinic fiscal year to be established by using the base per-visit rate set for the previous clinic fiscal year, and increasing that rate by the percentage increase in the number set out in the first quarter publication of Global Insight’s Health-Care Cost Review, Skilled Nursing Facility Total Market Basket; adjustments for that clinic fiscal year will be made to take into account any increase or decrease in the scope of services that


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the department has approved under (f) of this section, whether the change in the scope of services is proposed for that fiscal year or occurred in the preceding fiscal year.

(h) A health clinic may appeal, under 7 AAC 150.240, the final rate set by the department by submitting a written request to the commissioner, so that the commissioner receives the request no later than 30 days after the date that the final rate agreement letter is issued. (i) The amount, duration, and scope of primary care and ambulatory medical services provided by a health clinic are subject to the limits upon covered services under 7 AAC 105 - 7 AAC 160 as applied to other Medicaid recipients. (j) The department will pay a health clinic that is outside this state and that provides covered services to a Medicaid recipient eligible under 7 AAC 100 at the lesser of the (1) per-visit rate established by the agency responsible for Medicaid in the jurisdiction where the health clinic is located; or (2) the average per-visit rate established by the department for health clinics in this state. (k) In this section, (1) "ambulatory services" has the meaning given in 7 AAC 140.229; (2) "change in the scope of services" means

(A) the addition of a category of service to, or the deletion of a category of service from, those categories of service that a rural health clinic or federally qualified health center provides; or (B) an increase or decrease in the intensity of a category of service provided by a rural health clinic or federally qualified health center that may be reasonably expected to span at least one year; in this subparagraph, "intensity" means the cost of a category of service due to a change in the level of medical care provided to the population served by the rural health clinic or federally qualified health center;

(3) "medically necessary and appropriate" means (A) reasonably calculated to diagnose, correct, cure, alleviate, or prevent the worsening of medical conditions that endanger life, cause suffering or pain, result in illness or infirmity, threaten to cause or aggravate a disability, or cause physical deformity or malfunction; and (B) used because an equally effective more conservative or substantially less costly course of medical diagnosis or treatment is not available or suitable for the Medicaid recipient requesting the service; for purposes of this subparagraph, "course of treatment" includes mere observation or, if appropriate, no treatment at all. (Eff. 2/1/2010, Register 193)

Authority: AS 47.05.010 AS 47.07.040 AS 47.07.073 AS 47.07.030 AS 47.07.070 7 AAC 145.710. Calculating total health clinic visits. (a) For the purposes of calculating a rate under 7 AAC 145.700(c) for a rural health clinic, the department will consider the total number of visits to be the sum of the following: (1) the total number of visits for all recipients provided services by a full-


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time equivalent physician employed by the clinic; the department will calculate this figure by using the greater of the actual number of visits or a number that represents the minimum rural health clinic productivity standard, as follows:

(A) at least 2,100 visits per year per full-time equivalent physician employed by the clinic; (B) 50 percent of the number set out in (A) of this paragraph, for a rural health clinic’s first year of enrollment, and 75 percent of that number for a rural health clinic’s second year of enrollment;

(2) the total number of visits for all recipients provided services by a full-time equivalent physician assistant or advanced nurse practitioner employed by the clinic; the department will calculate this figure by using the greater of the actual number of visits or a number that represents the minimum rural health clinic productivity standard, as follows:

(A) at least 1,050 visits per year per full-time equivalent physician assistant or advanced nurse practitioner employed by the clinic; (B) 50 percent of the number set out in (A) of this paragraph, for a rural health clinic’s first year of enrollment, and 75 percent of that number for a rural health clinic’s second year of enrollment.

(b) For purposes of calculating a rate under 7 AAC 145.700(c) for a federally qualified health center, the department will consider the total number of visits to be the sum of the following: (1) the total number of visits for all recipients provided services by a full-time equivalent physician employed by the center; the department will calculate this figure by using the greater of the actual number of visits or a number that represents the minimum federally qualified health center productivity standard, as follows:

(A) at least 3,050 visits per year per full-time equivalent physician employed by an urban federally qualified health center; (B) at least 2,100 visits per year per full-time equivalent physician employed by a rural federally qualified health center; (C) 50 percent of the number set out in (A) or (B) of this paragraph, as applicable, for a federally qualified health center’s first year of enrollment, and 75 percent of that number for a federally qualified health center’s second year of enrollment;

(2) the total number of visits for all recipients provided services by a full-time equivalent midlevel practitioner employed by the center; the department will calculate this figure by using the greater of the actual number of visits or a number that represents the minimum federally qualified health center productivity standard, as follows:

(A) at least 1,550 visits per year per full-time equivalent midlevel practitioner employed by an urban federally qualified health center; (B) at least 1,050 visits per year per full-time equivalent midlevel practitioner employed by a rural federally qualified health center; (C) 50 percent of the number set out in (A) or (B) of this paragraph, as applicable, for a federally qualified health center’s first year of enrollment, and 75 percent of that number for a federally qualified health center’s second year of enrollment.


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(c) For the purposes of this section, a federally qualified health center is (1) an urban federally qualified health center if it is located within a metropolitan statistical area as determined by the United States Office of Management and Budget; (2) a rural federally qualified health center if it is located outside a metropolitan statistical area as determined by the United States Office of Management and Budget. (d) In this section, "midlevel practitioner" means (1) a physician assistant licensed under AS 08.64.107; (2) an advanced nurse practitioner licensed under AS 08.68.100; (3) a clinical psychologist licensed under AS 08.86.130; or (4) a clinical social worker licensed under AS 08.95.110. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.073 AS 47.07.030 AS 47.07.070 7 AAC 145.720. Health clinic re-basing. (a) The base years used to establish rates in future rate years for a rural health clinic or federally qualified health center will be changed periodically to more current years, and re-basing may be subject to audit. The department may determine the timing for a re-basing under this section and whether and when to conduct an audit. The department (1) will perform a re-basing no less than every four years; and (2) may perform a re-basing sooner than every four years. (b) The new base year rate will be calculated (1) using the Medicare cost reports for the two health clinic fiscal years ending no less than 12 months before the year in which re-basing occurs; and (2) in accordance with 7 AAC 145.710. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.073 AS 47.07.074 AS 47.07.070 7 AAC 145.730. Health clinic exceptional relief. A rural health clinic or federally qualified health center may apply, under 7 AAC 150.240, for exceptional relief from the rate-setting methodology in 7 AAC 145.700. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.073 AS 47.07.074 AS 47.07.070 7 AAC 145.739. Definitions. In 7 AAC 145.700 - 7 AAC 145.739, (1) "charity care" means health care services that

(A) a health clinic does not expect to result in cash payments; (B) result from a health clinic’s policy to provide health care services free of charge to an individual who meets certain financial criteria; and (C) are provided for by a health care provider, clinician, volunteer, or staff member, and for which the health care provider, clinician, volunteer or staff member does not expect to receive payment;

(2) "health clinic" has the meaning given in 7 AAC 140.229; (3) "visit" means the aggregate of face-to-face encounters, occurring on


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the same calendar day and at a single location, between the health clinic recipient and one or more rural health clinic professionals; for purposes of this paragraph, "aggregate of face-to-face encounters" does not include

(A) multiple face-to-face encounters in which, after the first encounter, the recipient suffers an additional illness or injury requiring additional diagnosis or treatment; (B) a face-to-face encounter for dental or mental health diagnosis or treatment that occurs on the same calendar day and single location as one or more face-to-face encounters for medical diagnosis or treatment; or

(C) charity care. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.073 AS 47.07.074 AS 47.07.070


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Chapter 150. Prospective Payment System; Other Payment. Section 10. Purpose of prospective payment system 20. Applicability of prospective payment system 30. Establishment of prospective rates 40. Prospective rates defined 100. Methodology and criteria for proportionate share payments to publicly owned or

operated hospitals 110. Methodology and criteria for proportionate share payments to privately owned or

operated hospitals 120. Methodology and criteria for proportionate share payments to state-owned or state-

operated hospitals 130. Establishment of uniform accounting, budgeting, and financial reporting 140. Processing of annual year-end report 150. Adjustment factors 160. Methodology and criteria for approval or modification of a payment rate 170. Allowable reasonable operating costs 180. Methodology and criteria for additional payments as a disproportionate share

hospital 190. Optional payment rate methodology and criteria for small facilities 200. Facility audits and desk reviews 210. Procedure for establishment of rates 220. Administrative appeal 230. Appeal procedures 240. Exceptional relief to prospective payment rate setting 990. Definitions 7 AAC 150.010. Purpose of prospective payment system. The purpose of this chapter is to implement the provisions of AS 47.07.040 and 47.07.070 - 47.07.900. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.071 AS 47.07.075 AS 47.05.040 AS 47.07.073 AS 47.07.900 AS 47.07.070 AS 47.07.074 AS 47.25.195 7 AAC 150.020. Applicability of prospective payment system. (a) All health facilities seeking payment from the department for services provided to Medicaid recipients in this state are subject to the provisions of this chapter. (b) To receive a change in a prospective payment rate, a health facility must obtain the department’s approval in accordance with the procedures set out in this chapter. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.070 7 AAC 150.030. Establishment of prospective rates. (a) The department will establish prospective payment rates in accordance with 7 AAC 150.210 for facilities not less than annually for each facility. (b) The department may establish temporary prospective payment rates. The


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final rate approved by the department supersedes the temporary rate, and payments will be adjusted in accordance with the final rate. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.070 7 AAC 150.040. Prospective rates defined. (a) Prospective payment rates are units of payment the department will pay to enrolled facilities that render services to Medicaid recipients. A facility may not charge the department an amount that exceeds the charge to the general public for the same service. (b) Prospective payment rates are per-day rates for (1) inpatient services rendered in general acute care, specialty, and inpatient psychiatric hospitals; and (2) long-term care facilities. (c) Prospective payment rates are a percentage of charges for outpatient hospital services, except for outpatient clinical laboratory services. (d) Prospective payment rates are per-procedure rates for (1) outpatient clinical laboratory services; and (2) ambulatory surgical centers. (e) Prospective payment rates are per-visit rates for (1) rural health clinics; and (2) federally qualified health centers. (f) The department will establish effective dates for all prospective payment rates. Services provided will be paid by the department at the rate in effect at the time the service was provided. For services provided that are to be paid under different prospective payment rates, the facility must provide the department with separate bills for each prospective payment rate period. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.070 7 AAC 150.100. Methodology and criteria for proportionate share payments to publicly owned or operated hospitals. (a) To implement the provisions of 42 U.S.C. 1396b regarding federal financial participation under Medicaid, and subject to legislative appropriations for that purpose, the department will make a public hospital proportionate share payment to, and receive a funding transfer of public money from, a hospital that qualifies under (1) of this subsection in order to ensure continued access to inpatient hospital services at certain hospitals that provide basic support for community or regional health care, and in order to secure for the state in accordance with AS 47.07.040 the optimum federal participation for inpatient hospital services in the state’s medical assistance program. The following procedures and requirements apply to a proportionate share payment under this subsection: (1) to qualify to receive a public hospital proportionate share payment under this subsection, a hospital must

(A) be (i) enrolled as a Medicaid provider of inpatient hospital services; (ii) located within the state; and (iii) a public facility;

(B) submit an application to the department


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(i) on a form designated by the department, in which the hospital attests that it meets the requirements of (A) of this paragraph, along with the specified documentation necessary to allow the department to verify that the hospital meets the requirements; and (ii) no later than the date specified in a written announcement distributed by the department; the department will not specify an application submission date that is earlier than 30 days after the date of the department’s written announcement; and

(C) enter into a written agreement with the department that controls the conditions for receipt of the public hospital proportionate share payment;

(2) the department will provide written notification to an applicant hospital of a decision that the hospital has or has not met the requirements of (1) of this subsection; unless a request for reconsideration is filed under (8) of this subsection, the department’s decision under this paragraph is the department’s final administrative action regarding whether an applicant hospital meets the requirements of (1) of this subsection; (3) the total amount available for distribution as public hospital proportionate share payments under this subsection will be established by the department each year, based on the department’s projection of hospital expenditures and within the payment limits of 42 C.F.R. 447.271 - 447.272; subject to legislative appropriation, payment of the amount the department determines to be available for public hospital proportionate share payments will be apportioned among qualifying hospitals based on the relative weight of each qualifying hospital’s occupancy level; (4) the department will determine the occupancy level of each qualifying hospital by using the hospital’s most recent Medicare cost report on file with the department on April 1 of a year for that hospital’s fiscal year that ended 24 months before the beginning of the hospital’s fiscal year in which the payment under this subsection is to be made; the hospital may not update or amend the Medicare cost report for the purpose of the proportionate share payment under this subsection; the department will determine the hospital’s occupancy level to be the percentage that results from dividing the total number of inpatient days by the total number of available bed days, as both are shown on the Medicare cost report described in this paragraph; (5) the department will assign an occupancy weight for each qualifying hospital in relation to its occupancy level, as follows:

Occupancy Level

Occupancy Weight

40 percent or more

1.00 unit

30 - 39 percent 1.05 units 20 - 29 percent 1.10 units 10 - 19 percent 1.15 units

less than 10 percent

1.20 units

(6) the department will determine the dollar value of an occupancy weight


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unit for the year of payment under this subsection by dividing the total amount of money available for public hospital proportionate share payments by the sum of the occupancy weight units of the qualifying hospitals; (7) the department will determine the amount of a public hospital proportionate share payment under this subsection to a qualifying hospital by multiplying the occupancy weight assigned to the hospital by the value of an occupancy weight unit as calculated under (6) of this subsection; the sum of the payments made to all qualifying hospitals is equal to the total amount of money available for public hospital proportionate share payments in that year; the department will notify each qualifying hospital in writing of the amount of that hospital’s payment as determined under this paragraph; unless a request for reconsideration is filed under (9) of this subsection, the department’s determination under this paragraph is the department’s final administrative action regarding the amount of a qualifying hospital’s proportionate share payment under this subsection; (8) a hospital aggrieved by the department’s decision under (2) of this subsection may request reconsideration of the decision by filing a request for reconsideration with the department, and sending a copy of the request to each qualifying hospital, no more than 10 days after the date of the department’s written notice under (2) of this subsection; the request for reconsideration must state the facts in the record that support a reversal of the initial decision; a qualifying hospital to which a request for reconsideration was sent may file with the department, no more than 10 days after the date the request was sent, a response to the request for reconsideration; the response must be based on facts in the record; the department’s decision on reconsideration is the department’s final administrative action on a reconsideration request under this paragraph; if the department does not issue a decision on reconsideration 30 days or less after the deadline for filing a response to the request for reconsideration, and does not waive the 30-day deadline, the request is considered denied by the department; the denial is the department’s final administrative action on a reconsideration request under this paragraph; (9) a qualifying hospital aggrieved by the department’s determination under (7) of this subsection may request reconsideration of the determination by filing a request for reconsideration with the department, and sending a copy of the request to each of the other qualifying hospitals, no more than 10 days after the date of the department’s written notice under (7) of this subsection; a request for reconsideration under this paragraph must state the facts in the record supporting a change in the payment amount; a qualifying hospital to which a request for reconsideration was sent may file with the department, no more than 10 days after the date the request was sent, a response to the request for reconsideration; the response must be based on facts in the record; the department’s decision on reconsideration is the department’s final administrative action on a reconsideration request under this paragraph; if the department does not issue a decision on reconsideration 30 days or less after the deadline for filing a response to the request for reconsideration, and does not waive the 30-day deadline, the request is considered denied by the department; the denial is the department’s final administrative action on a reconsideration request under this paragraph; (10) if a decision on reconsideration under this subsection results in a reapportioning of the amount determined under (3) of this subsection to be available for


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public hospital proportionate share payments, the department will calculate the necessary adjustment to the amount of the payment made under this subsection in that year to the qualifying hospitals; a qualifying hospital shall provide to the department any additional documentation requested by the department in order to make the necessary calculations; the department will notify a hospital in writing of any amount that must be repaid to the department by that hospital as a result of the adjustment; the hospital shall make the repayment to the department promptly after receipt of the department’s notice; if the repayment is not made 30 days or less after the date of the department’s notice, other payments due to that hospital under AS 47.07 may, consistent with state and federal law, be reduced by the amount not repaid. (b) In this section, unless the context requires otherwise, (1) "qualifying hospital" means a hospital that qualifies under (a)(1) of this section for a public hospital proportionate share payment; (2) "total number of available bed days" means the number shown on line 12, column 2, of worksheet S-3 of the qualifying hospital’s Medicare cost report; (3) "total number of inpatient days" means the number shown on line 12, column 6, of worksheet S-3 of the qualifying hospital’s Medicare cost report. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.070 7 AAC 150.110. Methodology and criteria for proportionate share payments to privately owned or operated hospitals. (a) To implement the provisions of 42 U.S.C. 1396b regarding federal financial participation under Medicaid, and subject to legislative appropriations for that purpose, the department will make a private hospital proportionate share payment to, and will require under (2) - (4) of this subsection that specific services be performed by, a hospital that qualifies under (1) of this subsection in order to ensure continued access to hospital services, and in order to secure for the state in accordance with AS 47.07.040 the optimum federal participation for inpatient hospital services in the state’s medical assistance program. The following procedures and requirements apply to a proportionate share payment under this subsection: (1) to qualify to receive a private hospital proportionate share payment under this subsection, a hospital must

(A) be enrolled as a Medicaid provider of inpatient hospital services; (B) be located within the state; (C) be a privately owned facility; and (D) submit to the department the Medicaid reporting forms for the qualifying year from the Medicaid Hospital and Long-Term Care Facility Reporting Manual, adopted by reference in 7 AAC 160.900;

(2) a qualifying hospital may receive proportionate share payments allocated to one or more of the following private hospital proportionate share classifications, if that hospital meets any additional criteria applicable to that classification, and subject to the limitations set out in (5) - (6) of this subsection:

(A) each qualifying hospital may receive payments for rural hospital assistance (RHA), if the qualifying hospital enters into an agreement with the department to provide support services in accordance with (4) of this


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subsection through a rural hospital and complies with the requirements of that agreement; (B) each qualifying hospital may receive payments for rural hospital clinic assistance (RHCA), if the qualifying hospital enters into an agreement with the department to provide support services in accordance with (4) of this subsection through a rural clinic and complies with the requirements of that agreement; (C) each qualifying hospital may receive payments for mental health clinic assistance (MHCA), if the qualifying hospital enters into an agreement with the department to provide mental health services through a mental health clinic and complies with the requirements of that agreement; (D) each qualifying hospital may receive payments for single-point-of-entry psychiatric assistance (SPEP), if the qualifying hospital enters into an agreement with the department to provide single-point-of-entry psychiatric services and complies with the requirements of that agreement; (E) each qualifying hospital may receive payments for designated evaluation and treatment assistance (DET), if the qualifying hospital

(i) is designated as an evaluation and treatment facility as required by 7 AAC 72; and (ii) enters into an agreement with the department to provide designated evaluation and treatment services and complies with the requirements of that agreement;

(F) each qualifying hospital may receive payments for children’s medical care assistance (CMC), if the qualifying hospital enters into an agreement with the department for health and hospital care expenses for children and complies with the requirements of that agreement; (G) each qualifying hospital may receive payments for institutional community health care assistance (ICHC), if the qualifying hospital enters into an agreement with the department for health and hospital care expenses for individuals in institutions who are not Medicaid-eligible, and complies with the requirements of that agreement; (H) each qualifying hospital may receive payments for substance abuse treatment provider assistance (SATP), if the qualifying hospital enters into an agreement with the department to provide substance abuse treatment through a substance abuse treatment provider and complies with the requirements of that agreement;

(3) in an agreement under (2) of this subsection, the department may authorize the qualifying hospital to provide the required services directly, through the purchase of services, or through a person, clinic, or hospital designated by the department; a payment made under this section is not an allowable cost under the facility rate setting methodology set out in 7 AAC 150.010 - 7 AAC 150.040 and 7 AAC 150.130 - 7 AAC 150.210; (4) for purposes of an agreement under (2)(A) or (B) of this subsection, the support services that a qualifying hospital provides must include one or more of the following:

(A) health services at the rural hospital site or rural clinic site; the


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qualifying hospital may include, as services, the services of a primary care provider, nurse midwife services, obstetrical services, and pediatrician’s services; (B) assistance in arranging safe transport for those who require emergency transport and services; (C) other health services agreed to by the qualifying hospital and the department;

(5) the total amount available for distribution as private hospital proportionate share payments under this subsection will be established by the department each year, based on the department’s projection of hospital expenditures and within the payment limits of 42 C.F.R. 447.271 - 447.272; subject to legislative appropriation, payment of the amount the department determines to be available for private hospital proportionate share payments will be apportioned among qualifying hospitals; (6) beginning August 11, 2004, the department will allocate the following percentage of the private hospital proportionate share payments for each payment year by proportionate share classification:

(A) to the rural hospital assistance (RHA) private hospital classification, one percent; (B) to the rural health clinic assistance (RHCA) private hospital classification, 54 percent; (C) to the mental health clinic assistance (MHCA) private hospital classification, 23 percent; (D) to the single-point-of-entry psychiatric (SPEP) private hospital classification, six percent; (E) to the designated evaluation and treatment (DET) private hospital classification, one percent; (F) to the children’s medical care (CMC) private hospital classification, eight percent; (G) to the institutional community health care (ICHC) private hospital classification, one percent; (H) to the substance abuse treatment provider (SATP) private hospital classification, six percent;

(7) each payment for the private hospital proportionate share classifications will be calculated within each classification based on the number of encounters to be performed by the qualifying hospital for that classification, as specified in the agreement required under (2) of this subsection for that classification, divided by the total number of encounters to be performed by all qualifying hospitals within that classification, as specified in the agreements required for that classification; the resulting percentage will be multiplied by the allocation amount applicable to that classification, as calculated in (5) - (6) of this subsection; (8) on or before the qualification date, the department will send to each privately owned hospital a list of the qualifying hospitals and the amount of the payments for the upcoming payment year; the total amount available for distribution as private hospital proportionate share payments under this subsection will be established by the department each year, based on the department’s projection of hospital expenditures and within the payment limits of 42 C.F.R. 447.271 - 447.272; the department’s determination under this paragraph is the department’s final administrative action


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regarding (A) whether a hospital is a qualifying hospital, unless a request for reconsideration is filed under (10) of this subsection; and (B) the amount of a qualifying hospital’s proportionate share payment under this subsection, unless a request for reconsideration is filed under (11) of this subsection;

(9) to optimize, consistent with AS 47.07 and this chapter, the use of federal money allotted to private hospital proportionate share payments, the department may enter into other agreements under (2)(A) - (H) of this subsection, if

(A) the amount of the federal allotment is greater than the sum of payments listed under (8) of this subsection; (B) the part of the federal allotment allocated under (6) of this subsection to a particular classification is not fully used within that classification; or (C) after issuance of the list under (8) of this subsection, part of the federal allotment becomes available for distribution because an agreement or other criterion required under (2) of this subsection was not reached or satisfied;

(10) a hospital aggrieved by the department’s decision under (8) of this subsection, regarding whether a hospital is a qualifying hospital, may request reconsideration of the decision by filing a request with the department, and sending a copy of the request to each qualifying hospital, no more than 10 days after the date of the department’s list under (8) of this subsection; a request for reconsideration under this paragraph must state the facts in the record that support a reversal of the initial decision; a qualifying hospital to which a request for reconsideration was sent may file with the department, no more than 10 days after the date the request was sent, a response to the request for reconsideration; the response must be based on facts in the record; the department’s decision on reconsideration under this paragraph is the department’s final administrative action on a reconsideration request under this paragraph; if the department does not issue a decision on reconsideration 30 days or less after the deadline for filing a response to the request for reconsideration, and does not waive the 30-day deadline, the request is considered denied by the department; the denial is the department’s final administrative action on a reconsideration request under this paragraph; (11) a hospital aggrieved by the department’s decision under (8) of this subsection, regarding the amount of a qualifying hospital’s proportionate share payment under this subsection, may request reconsideration of the decision by filing a request with the department, and sending a copy of the request to each of the other qualifying hospitals, no more than 10 days after the date of the department’s list under (8) of this subsection; if the department has made the private hospital proportionate share payment under this subsection to the qualifying hospital, the department will accept and consider a request for reconsideration under this paragraph only after return of any unearned portion of the payment is made; a request for reconsideration under this paragraph must state the facts in the record that support a change in the payment amount; a qualifying hospital to which a request for reconsideration was sent may file with the department, no more than 10 days after the date the request was sent, a response to the request for reconsideration; the response must be based on facts in the record; the department’s decision on reconsideration under this paragraph is the department’s final administrative action on a


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reconsideration request under this paragraph; if the department does not issue a decision on reconsideration 30 days or less after the deadline for filing a response to the request for reconsideration, and does not waive the 30-day deadline, the request is considered denied by the department; the denial is the department’s final administrative action on a reconsideration request under this paragraph; (12) the administrative appeal process provided by 7 AAC 150.220 and the exceptional relief process set out in 7 AAC 150.240 are not available to a hospital disputing an item on the department’s list under (8) of this subsection of qualifying hospitals and amounts; (13) unless the department considers it impractical, the department will recalculate and reallocate the proportionate share eligibility and payments for all hospitals and will recoup payments from all hospitals on a prorated basis if the

(A) proportionate share eligibility and payment for any private hospital will be recalculated as a result of a decision under (10) or (11) of this subsection or of a court decision; or (B) outcome of a decision under (10) or (11) of this subsection or of a court decision would cause the total private hospital proportionate share payments to exceed the federal allotment for the federal fiscal year in which the payment rate was in effect.

(b) In this section, unless the context requires otherwise, (1) "encounter" means a unit of service, visit, or face-to-face contact that is a covered service under an agreement with the department as required under this section; (2) "payment year" means the state fiscal year; (3) "qualification date" means July 1 of each year; (4) "qualifying hospital" means a hospital that qualifies under (a)(1) of this subsection for a private hospital proportionate share payment; (5) "qualifying year" means the hospital’s most recent fiscal year that the department determines complete. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.070 AS 47.07.030 7 AAC 150.120. Methodology and criteria for proportionate share payments to state-owned or state-operated hospitals. (a) To implement the provisions of 42 U.S.C. 1396b regarding federal financial participation under Medicaid, and subject to legislative appropriations for that purpose, the department will make a state hospital proportionate share payment to, and may require specific services to be performed by, a hospital that qualifies under (1) of this subsection in order to ensure continued access to inpatient and outpatient hospital services or other health services, and in order to secure for the state in accordance with AS 47.07.040, the optimum federal participation for inpatient hospital services in the state’s medical assistance program. The following procedures and requirements apply to a proportionate share payment under this subsection: (1) to qualify for a state hospital proportionate share payment under this subsection, a hospital must be

(A) a state-owned or state-operated Medicaid provider of inpatient


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hospital services; and (B) located within the state;

(2) the total amount available for distribution as state hospital proportionate share payments under this subsection will be established by the department each year, based on the department’s projection of hospital expenditures and within the payment limits of 42 C.F.R. 447.271 - 447.272; subject to legislative appropriation, payment of the amount the department determines to be available for state hospital proportionate share payments will be apportioned among qualifying hospitals. (b) In this section, "qualifying hospital" means a hospital that qualifies under (a)(1) of this section for a state hospital proportionate share payment. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.070 AS 47.07.030 7 AAC 150.130. Establishment of uniform accounting, budgeting, and financial reporting. (a) The department adopts a uniform system of accounting, financial reporting, budgeting, cost allocation, and prospective rate setting for facilities. The financial reporting, budgeting, and cost allocation requirements are described in the Medicaid Hospital and Long-Term Care Facility Reporting Manual, adopted by reference in 7 AAC 160.900. Each facility shall use the manual when submitting information required by the department pertaining to prospective payment rates of the Medicaid program. Each facility shall maintain accounting records at the level of detail established by the "Overview of the Chart of Accounts" in the publication entitled Chart of Accounts for Hospitals, adopted by reference in 7 AAC 160.900. Upon receipt of a facility’s request that is described in detail satisfactory to the department, the department may approve an alternate reporting system for information required by this section. (b) If a facility requests inclusion of certificate of need capital, the facility shall submit its budget information to the department not less than 60 days before the beginning of the facility’s fiscal year. The budget information must contain that information specified in the department’s manual and must be submitted in the form and manner specified in the manual. If more than one facility is operated by the reporting organization, the information required by this subsection must be reported for each facility separately. The chief executive officer and chairperson of the governing board of the facility shall attest that the information submitted under this subsection, including any subsequent modifications, has been examined by that person and to the best of that person’s knowledge the information is correct. (c) Each facility shall submit its year-end report to the department staff that oversees Medicaid payment rates no more than 150 days after the close of the facility’s fiscal year, in a form and manner as specified in the manual, including the Medicare cost reports and audited financial statements specific to the facility and matching the same time period as the Medicare cost report. If more than one facility is operated by the reporting organization, the information required by this subsection must be reported separately for each facility. The year-end report submitted under this subsection, including any subsequent modification of it, must be certified by the facility’s chief administrative or fiscal officer, who, under oath, indicates that, to the best of the officer’s knowledge, all reports have been prepared in accordance with (a) of this section.


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(d) The department will consider facility requests to amend a report submitted under this section if, no more than 30 days after it has filed its year-end report, a facility submits a written request that the department include specific audit adjustments in the desk review audit report issued under 7 AAC 150.200, and if the facility has timely filed its year-end report in accordance with (c) of this section. The department will consider a request to amend a Medicare cost report only if the facility demonstrates that the same request is on file with the facility’s fiscal intermediary to the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services. The department will review a facility’s request, together with documentation provided in support of that request, and determine appropriate adjustments, if any, to include in the audit report. (e) Rural health clinics and federally qualified health centers are subject to the reporting requirements set out in 7 AAC 140.200. (f) Ambulatory surgical centers are exempt from the reporting requirements of (b) of this section. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.070 AS 47.07.073 AS 47.07.040 AS 47.07.071 AS 47.07.074 7 AAC 150.140. Processing of annual year-end report. (a) The department will process facilities’ annual year-end reports required by 7 AAC 150.130(c) in the manner set out in (a) - (e) of this section, unless the facility is a rural health clinic or ambulatory surgical center. Each annual year-end report will be date-stamped upon receipt by the department. The department will acknowledge the date of receipt in a written notice. (b) No more than 20 days after receipt of an annual year-end report, the department will review the report to determine whether all required forms are complete. (c) Written notice will be provided by mail to the facility during the 20-day review period if the department determines that the annual year-end report does not contain all required and completed forms. If the department does not provide written notice during the 20-day period, the department will treat the year-end report as complete. In the notice, the department will clearly identify the deficiencies and the time by which the corrected or modified annual year-end report must be received by the department. The department will give the facility at least seven days following receipt of the notice to return to the department the corrected or modified annual year-end report. (d) If the data requested under (c) of this section is returned to the department during the specified period, the department will make reasonable efforts to continue the processing of the annual year-end report as if a delay had not occurred. (e) If the department determines under (b) of this section that the annual year-end report is complete, the department will begin processing and verifying the data contained in the report and prepare findings and recommendations as needed. (f) A copy of the department’s findings and recommendations will be mailed to the facility not less than 30 days before the date set for the public hearing to consider the facility’s proposed prospective payment rate. (g) A facility may submit a response to the department’s findings and recommendations. The response must be received by the department not less than five days before the date set for the public hearing to consider the facility’s proposed


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prospective payment rate. (h) If a facility is an ambulatory surgical center, the department will prepare findings and recommendations in the manner set out in (f) and (g) of this section. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.071 AS 47.07.073 AS 47.07.070 7 AAC 150.150. Adjustment factors. (a) To calculate adjustment factors for facility fiscal years, the department will use the most recent quarterly publication of Global Insight’s Health Care Cost Review available 60 days before the beginning of a facility’s fiscal year, as follows: (1) for general acute care, specialty, and inpatient psychiatric hospitals’ noncapital allowable costs, the department will utilize the Global Insight Hospital Market Basket; (2) for general acute care, specialty, and inpatient psychiatric hospitals’ allowable capital costs and allowable home office capital costs will be adjusted using Global Insight Health Care Costs, Building Cost Index, CMS New 1997-based PPS Hospital Capital IPI; (3) for long-term care facilities’ noncapital allowable costs, the department will utilize the CMS Nursing Home without Capital Market Basket; (4) long-term care facilities’ allowable capital costs, and allowable home office capital costs will be adjusted using the Skilled Nursing Facility Total Market Basket Capital Cost component. (b) For facility fiscal years beginning after December 31, 2000, and on each July 1 thereafter, the department will use the most recent quarterly publication available 60 days before July 1 of Global Insight’s Health Care Cost Review, Hospital Market Basket for yearly adjustment factors applied to ambulatory surgical centers. (c) If the facility’s year-end report is submitted timely under 7 AAC 150.130, the adjustment factors calculated under (a) of this section will be effective for the prospective payment rates at the beginning of the facility’s fiscal year. (d) The adjustment factors calculated under (a) of this section will be effective 90 days after the beginning of the facility’s fiscal year if the facility’s year-end report is submitted not more than 30 days late under 7 AAC 150.130. (e) The adjustment factors calculated under (a) of this section will be effective 180 days after the beginning of the facility’s fiscal year if the facility’s year-end report is submitted not more than 90 days late under 7 AAC 150.130. (f) If the facility’s year-end report is submitted more than 90 days late under 7 AAC 150.130, the adjustment factors calculated under (a) of this section do not apply during the facility’s fiscal year. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.071 AS 47.07.073 AS 47.07.070 7 AAC 150.160. Methodology and criteria for approval or modification of a payment rate. (a) The department will use the following methodology and criteria in reviewing and establishing prospective payment rates for the Medicaid program: (1) the department will consider the following with the relative


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importance of each criterion being a matter of department discretion: (A) whether the costs are related to patient care and are attributable to the Medicaid program; (B) whether the payment rate is reasonably related to costs;

(2) the department will set annual rates established for the facility’s fiscal year; (3) base years may be changed to more current years and may be subject to audit; the department may determine the timing for a re-basing under this paragraph and whether and when to conduct an audit; (4) for all facilities, except facilities with rate agreements established under 7 AAC 150.190, the department

(A) will perform a re-basing for the first fiscal year beginning after notification to the facilities that a re-basing will be done; (B) will perform a re-basing no less than every four years; and (C) may perform a re-basing sooner than every four years.

(b) The department will express the inpatient hospital payment rate for general acute care, specialty, and inpatient psychiatric hospitals as a per-day rate. The per-day inpatient hospital payment rate will be based on allowable costs calculated from the appropriate base year adjusted Medicare cost report as follows: (1) the noncapital routine portion of the prospective per-day rate is the base year’s facility-specific Medicaid noncapital routine average cost, calculated as follows, and updated to the prospective year based on adjustment factors identified in 7 AAC 150.150:

(A) the Medicaid cost of each reimbursable routine cost center is determined by dividing the total noncapital costs in each reimbursable routine cost center by the total patient days in that cost center and multiplying that quotient by the allowable paid Medicaid patient days in that cost center; (B) the sum of the Medicaid costs for each reimbursable routine cost center is divided by the sum of the allowable paid Medicaid patient days, resulting in the base year’s facility-specific Medicaid noncapital routine average cost;

(2) the routine capital portion of the prospective per-day rate is the base year’s facility-specific Medicaid inpatient routine average capital cost, calculated as follows, and updated to the prospective year based on adjustment factors identified in 7 AAC 150.150:

(A) the Medicaid cost of each reimbursable capital cost center is determined by dividing the total capital costs in each reimbursable routine capital cost center by the total patient days in that cost center and multiplying that quotient by the allowable paid Medicaid patient days in that cost center; (B) the sum of the Medicaid costs for each reimbursable routine capital cost center is divided by the sum of the allowable paid Medicaid patient days, resulting in the base year’s facility-specific Medicaid routine average capital cost;

(3) the ancillary capital portion of the prospective per-day payment rate is determined by calculating the percentage of capital cost for each ancillary cost center, multiplying the percentage by the related Medicaid patient ancillary costs from the base


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year adjusted Medicare cost report, by cost center, and totaling the calculated capital costs from all cost centers; the resulting total is divided by the sum of the Medicaid patient days from the base year and updated to the prospective year based on adjustment factors identified in 7 AAC 150.150; (4) the noncapital ancillary portion of the prospective per-day rate is the sum of Medicaid inpatient noncapital ancillary costs from the base year divided by the facility’s Medicaid patient days from the base year; the resulting per-day inpatient noncapital ancillary cost is updated to the prospective year based on adjustment factors identified in 7 AAC 150.150; total Medicaid inpatient ancillary costs less the capital portion of the Medicaid inpatient ancillary costs as determined in (3) of this subsection equals the total noncapital Medicaid inpatient ancillary costs to be used for this portion of the rate; (5) for purposes of this subsection, nursery days constitute patient days and swing-bed days do not constitute patient days; (6) for purposes of this subsection, the costs associated with swing-bed services, determined by multiplying the number of swing-bed days by the swing-bed rate in effect in the base year, are removed before calculating the acute care per-day rate; (7) for purposes of this subsection, Medicaid patient days are

(A) the covered days from the MR-0-14 report for routine noncapital and routine capital costs; and (B) facility-reported Medicaid patient days for ancillary noncapital and ancillary capital costs; after re-basing, the department may use either facility-reported Medicaid patient days or covered days from the MR-0-14 report for ancillary noncapital and capital costs;

(8) for purposes of this subsection, and except for critical access hospitals designated under 7 AAC 12.190, costs are the lower of

(A) Medicaid inpatient costs; the department will calculate those costs as the sum of

(i) Medicaid inpatient routine costs, obtained by dividing the number of Medicaid inpatient days by the total number of hospital inpatient days, as those numbers are given in the Medicare cost report and adjusted in accordance with 7 AAC 150.170 and 7 AAC 150.200, and by multiplying the resulting quotient by the total hospital inpatient routine costs, as given in the adjusted Medicare cost report; and (ii) Medicaid inpatient ancillary costs, obtained by multiplying for each cost center the total Medicaid charges, as given in the adjusted Medicare cost report, by the cost-to-charge ratio for that cost center, and by totaling the resulting products for the aggregate amount of inpatient ancillary costs; or

(B) 100 percent of charges in the aggregate to the general public; the department will calculate those charges as the sum of the

(i) inpatient routine charges to Medicaid patients, as reported in the MR-0-14 report; and

(ii) inpatient charges for ancillary services to Medicaid patients, as those charges are determined from the adjusted Medicare cost report;


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(9) for purposes of this subsection, if the department determines that a provision in this chapter became effective after the last adjustment under 7 AAC 150.150 and the provision may change the per-day rate by a material amount, the department will apply the provision when the per-day rate is updated to the prospective year by the adjustment factors in 7 AAC 150.150. (c) The department will express outpatient general acute care hospital payment rates as a percentage of charges calculated as follows: (1) each outpatient cost-to-charge ratio by cost center from the adjusted Medicare cost report is multiplied by the corresponding Medicaid outpatient charges to calculate the Medicaid outpatient costs by cost center; (2) the sum of Medicaid outpatient costs by cost center is divided by the sum of Medicaid outpatient charges by cost center to obtain the percentage rate; (3) the applicable outpatient cost-to-charge percentage may not exceed 100 percent; (4) for purposes of this subsection, charges for the first payment rates beginning from January 1, 2001, through December 31, 2001, are the facility-reported outpatient charges; (5) under this subsection, the laboratory cost center is not included in the cost centers; (6) for purposes of this subsection, if the department determines that a provision in this chapter became effective after the last adjustment under 7 AAC 150.150 and the provision may change the outpatient rate by a material amount, the department will apply the provision when the per-day rate established under (b) of this section is updated to the prospective year by the adjustment factors in 7 AAC 150.150. (d) The department will determine a rate of payment for a hospital outpatient laboratory service based on reasonable costs as determined under 42 C.F.R. 405.515, adopted by reference in 7 AAC 160.900. (e) The department will express rates for long-term care facilities as a per-day rate calculated as follows: (1) the long-term care noncapital routine portion of the prospective per-day rate is determined by adding together the long-term care noncapital routine costs from the base year adjusted Medicare cost report; the resulting total is divided by the sum of the facility’s long-term care patient days from the base year; the resulting per-day noncapital routine cost is updated to the prospective year based on adjustment factors identified in 7 AAC 150.150; (2) the routine capital portion of the prospective per-day rate is the long-term care routine capital costs from the facility’s base year adjusted Medicare cost report divided by the facility’s total long-term care patient days from the base year; for purposes of this paragraph, the long-term care patient days are the greater of

(A) the total actual patient days; or (B) 85 percent of licensed capacity days;

(3) the ancillary capital portion of the prospective per-day payment rate is determined by calculating the percentage of capital cost for each ancillary cost center and multiplying the percentage by the related Medicaid long-term care ancillary costs from the base year, by cost center, and totaling the calculated capital costs from all cost centers; the resulting total is divided by the sum of the Medicaid long-term care patient


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days from the base year; (4) the noncapital ancillary portion of the prospective per-day rate is the Medicaid long-term care noncapital ancillary costs from the base year divided by the sum of the facility’s Medicaid long-term care patient days from the base year; the resulting per-day noncapital long-term care ancillary cost is updated to the prospective year based on adjustment factors identified in 7 AAC 150.150; the total Medicaid long-term care ancillary costs less the capital portion of the Medicaid long-term care ancillary costs as determined in (3) of this subsection equals the total noncapital Medicaid long-term care ancillary costs to be used for this portion of the rate; (5) for purposes of this subsection, Medicaid long-term care patient days are the covered days from the MR-0-14 report; (6) for purposes of this subsection, if the department determines that a provision in this chapter became effective after the last adjustment under 7 AAC 150.150 and the provision may change the per-day rate by a material amount, the department will apply the provision when the per-day rate is updated to the prospective year by the adjustment factors in 7 AAC 150.150. (f) If the facility is granted a certificate of need under AS 18.07 to make an expenditure of at least $5,000,000, the department will allow a change in the per-day rates calculated under this section for certificate of need capital costs as follows: (1) the department will change the per-day rate when the assets that have a certificate of need are placed in service by the facility after the base year; (2) for facilities that provide both a long-term care component and a general acute care hospital component, budgeted capital will be allocated to each component based upon anticipated capital use for each component as determined by the department from the appropriate certificate of need documents and supporting documentation; (3) if a facility is granted a certificate of need to make an expenditure of at least $5,000,000 to construct additional beds, additional capital payment add-on amounts to the per-day rate include the base year’s patient days plus additional patient days associated with the additional beds; the additional days are calculated as the facility’s base year occupancy percentage multiplied by 80 percent and multiplied by the additional beds approved in the certificate of need; the resulting figure is further multiplied by 365; (4) the capital component of the rates will be adjusted to reflect appropriate capital costs for the prospective rate year based on certificate of need documentation, assets retired in conjunction with the certificate of need, and Medicare cost reporting requirements. (g) If a new facility or a new psychiatric unit in a general acute care hospital is licensed or certified, the rates for the facility will be calculated as follows: (1) for general acute care and specialty hospitals, the inpatient per-day rate and the outpatient payment percentage will be established at the statewide weighted average of inpatient per-day rates and outpatient payment percentages of general acute care and specialty hospitals in accordance with this section for the most recent 12 months of permanent rates; patient rates are the statewide weighted average using the base year’s patient days and the outpatient percentages are the statewide weighted average using the base year’s outpatient charges;


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(2) for an inpatient psychiatric hospital, or a separately licensed or certified psychiatric unit in a general acute care hospital, the inpatient per-day rate will be established at the statewide weighted average of inpatient per-day rates of psychiatric hospitals for the most recent 12 months of permanent rates; rates are the statewide weighted average using the base year’s patient days; (3) for long-term care facilities, the rate is the sum of the

(A) swing-bed rate in effect at the start of the facility’s rate year, less the average capital costs contained in the swing-bed rate; and (B) capital costs identified by the new facility, subject to the limitations described in 7 AAC 150.170, using the greater of occupancy rates approved in the certificate of need or 80 percent of licensed beds;

(4) rates for a new facility or a new separately licensed or certified psychiatric unit in a general acute care hospital will be established under (b) - (f) of this section after two full fiscal years of cost data is reported. (h) The department will determine a rate of payment for ambulatory surgical centers based on the federal Medicare ambulatory surgical center payment rates for federal fiscal year 2000, adopted by reference in 7 AAC 160.900, and as adjusted annually by the adjustment factors in 7 AAC 150.150. (i) The department will determine a rate of payment for swing-bed services in accordance with 42 C.F.R. 447.280, adopted by reference in 7 AAC 160.900. (j) Prospective payment rates for facilities that are calculated and paid on a per-day rate basis will be set at a level no greater than the per-day rates proposed in the certificate of need application and other information the applicant provided as a basis for approval of the certificate of need for the first year. The limitation set out in this subsection applies for the first year and for the two years immediately following the first year that at least one of the following events occurs: (1) opening of the new or modified health care facility; (2) alteration of the bed capacity; (3) the implementation date of a change in offered categories of health service or bed capacity. (k) The per-day rates calculated under this section may not exceed corresponding charges rendered to the general public. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.070 7 AAC 150.170. Allowable reasonable operating costs. (a) Allowable costs for prospective rates are the costs from the appropriate base year’s Medicare cost report, in accordance with Medicare requirements and regulations, as audited or adjusted in accordance with this section. The department will consider only costs that are consistent with efficient, cost-effective management and operations. Only operating costs that are directly related to the delivery of health care services to Medicaid patients will be allowed for the purpose of rate setting. (b) Operating costs are the costs of providing health care services to Medicaid patients that are necessary and reasonable and that are not excluded by this section. The following costs are excluded or otherwise limited as set out in this subsection: (1) advertising cost: the cost of advertising, which includes marketing, is allowable only to the extent that the advertising is directly related to the care of patients


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at the facility; the reasonable cost of only the following types of advertising and marketing is allowable:

(A) announcing the opening of or change of name of a facility; (B) recruiting for personnel; (C) advertising for the procurement or sale of items; (D) obtaining bids for construction or renovation; (E) advertising for a bond issue; (F) informational listing of the provider in a telephone directory; (G) listing a facility’s hours of operation; (H) advertising specifically required as part of a facility’s accreditation process;

(2) nursing cost: the cost of nursing staff in a long-term care facility is allowable as a routine cost only; the cost of nursing personnel is not an allowable ancillary cost even if the nursing personnel are working under the supervision of a licensed patient care provider; (3) physician cost: physician compensation costs and charges associated with providing care to patients are not allowable for purposes of calculating a prospective payment rate; (4) medical service cost: medical services, including those services described in 7 AAC 145.650(c)(5), that a long-term care unit or facility is not licensed to provide, are not an allowable long-term care unit or facility ancillary cost; (5) management fees: a facility must file with its year-end report, as described in 7 AAC 150.130, any management agreement, or change to a management agreement with a firm that, or an individual other than an employee who, will manage the facility during the period the prospective rate is effective; management fees paid to a firm or to an individual who is not an employee of the facility or of the facility’s home office are allowable costs only if the

(A) fees are paid in accordance with the terms of a written management agreement that creates a principal/agent relationship between the facility and the manager, and sets out the items, services, and activities to be provided by the manager; (B) facility documents the actual delivery of management services; (C) services do not duplicate management services otherwise provided to the facility; and (D) management fees are reasonably attributable to the management of the local facility;

(6) costs are authorized by a certificate of need: costs authorized by a certificate of need are allowable as follows:

(A) interest, depreciation, and other capital costs will not be recognized on the entire basis of assets purchased after January 18, 1990, if a certificate of need was required and the facility did not secure one; recognition of interest, depreciation, and other capital costs for which a certificate of need was required will be no greater than the amounts described and approved in the certificate of need application and other information the applicant provided as a basis for approval of the certificate of need;


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(B) prospective payment rates for facilities that are calculated and paid on a per diem rate basis will be no greater than the per diem rates proposed in the certificate of need application and other information the applicant provided as a basis for approval of the certificate of need for the first year during which the following listed items are available for use and for the two years immediately following that first year:

(i) opening of the new or modified health care facility; (ii) alteration of the bed capacity; or (iii) the implementation date of a change in offered categories of health service or bed capacity;

(C) in determining whether interest, depreciation, and other capital costs exceed those amounts approved under a certificate of need, and for determining the maximum prospective per diem rate approved under a certificate of need, the department will consider the

(i) terms of issuance describing the nature and extent of the activities authorized by the certificate; and (ii) facts and assertions presented by the facility in the application and certificate of need review record, including purchase or contract prices, the rate of interest identified or assumed for any borrowed capital, lease costs, donations, development costs, staffing and administration costs, and other information the facility provided as a basis for approval of the certificate of need;

(D) if a certificate is issued authorizing only part of the activities proposed in a certificate of need application, the limitation of rates will be based upon the factors noted under (C) of this paragraph;

(7) pharmaceutical supplies and materials: pharmaceutical supplies and materials for patients who are residents of a long-term care facility, or an intermediate care facility for the mentally retarded, are paid in accordance with 7 AAC 145.650(c) and 7 AAC 145.660(c); these costs and charges, with the exception of the costs of nonprescription drugs dispensed as ordered by a physician, are excluded from facility prospective payment rates; all costs associated with the administration and delivery of prescription pharmacy supplies and material costs are not ancillary; (8) intergovernmental transfers: an intergovernmental transfer of money is not an allowable cost for purposes of calculating a prospective payment rate; (9) costs of certified registered nurse anesthetists: costs of certified registered nurse anesthetists are allowable costs under this section if those costs are not covered under a separate provider payment program; (10) swing-bed costs: swing-bed costs, determined by multiplying the base year total swing-bed days by the swing-bed rate in effect for that period, are not allowable costs under this section; (11) ancillary costs: ancillary costs covered under a separate provider agreement or alternate resources are not allowable costs under this section; (12) allowable home office costs: allowable home office costs may not exceed the most recent Medicare-audited Medicare home office cost statement available in the department’s files 60 days before the beginning of a re-based prospective rate year; if the Medicare-audited Medicare home office cost statement is not from the same year as


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the facility’s base year, the costs will be inflated to the facility’s base year using the methodology described in 7 AAC 150.150; (13) provider-based clinic costs: the department will not allow provider-based clinic costs; for purposes of this paragraph, provider-based clinic costs include

(A) capital costs for a clinic, administrative costs for a clinic, general health care or nursing services in a clinic, and any other allocated overhead costs for a clinic; and (B) items reported under a "clinic" component or a "clinic" cost center of a hospital; for purposes of this subparagraph, the department will consider a component or cost center to be a "clinic" component or "clinic" cost center if that component or cost center is established primarily for the provision of outpatient physicians’ or nurse practitioners’ services;

(14) advocacy and lobbying activity expenses: advocacy expenses, lobbying activity costs and special assessments to fund the preparation of advocacy and position papers are not allowable costs; for dues, meetings, conference fees, and memberships in trade organizations and associations, a facility may claim up to 75 percent as allowable costs; health care training expenses will not be considered unallowable solely because a trade organization or association sponsors the training; (15) nonallowable cost related to a court or administrative proceeding initiated by a facility: costs incurred by a facility related to a court or administrative proceeding originally initiated by a facility are not allowable under this section, except that costs incurred on an issue in a court or administrative proceeding originally initiated by a facility are allowable operating costs under this section if the facility is the prevailing party on the issue under a final order, and the rules governing the proceeding make no provision for award of fees and costs to a prevailing party; allowable operating costs under this paragraph related to a court or administrative proceeding originally initiated by the facility are limited to expenses incurred in the base year. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.071 AS 47.07.073 AS 47.07.070 7 AAC 150.180. Methodology and criteria for additional payments as a disproportionate share hospital. (a) A qualifying hospital that provides services to a disproportionate share of low-income patients with special needs is eligible for Medicaid payments as a disproportionate share hospital (DSH). These payments are in addition to the Medicaid payment rate established under 7 AAC 150.160 or 7 AAC 150.190. The department will not award payments under this section to a qualifying hospital in a total amount that exceeds the facility-specific limit calculated under (g)(3) of this section. (b) To qualify for additional payments under this section as a DSH, a hospital must meet the following criteria for each qualifying year: (1) the hospital must be a general acute care hospital, a specialty hospital, or an inpatient psychiatric hospital; (2) unless it qualifies for the exception set out in 42 U.S.C. 1396r-4(d)(2), the hospital must meet the obstetrical staffing requirements of 42 U.S.C. 1396r-4(d), and must provide the names and Medicaid provider numbers of at least two obstetricians who


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meet the requirements of that section; (3) the hospital must have a minimum Medicaid utilization rate of not less than one percent for the qualifying year; for purposes of this paragraph, the Medicaid utilization rate is calculated by dividing the hospital’s number of Medicaid-eligible inpatient days by the hospital’s total number of inpatient days provided to all patients; (4) on or before October 1 of the calendar year that precedes the payment year, the hospital must submit to the department the following forms and documentation:

(A) the Medicare cost report filed for the qualifying year; (B) Medicaid reporting forms for the qualifying year from the Medicaid Hospital and Long-Term Care Facility Reporting Manual, adopted by reference in 7 AAC 160.900; (C) a log for the qualifying year for each patient having uninsured care; the log must be prepared using the Medicaid Log of Uninsured Care Reporting Form, adopted by reference in 7 AAC 160.900; the hospital must certify the log as accurate; the log must specify, in sufficient detail for the department to verify uninsured care,

(i) charges; (ii) admissions; (iii) patient days; (iv) any payments made by the patient, or on behalf of the patient by a third party, for services; and (v) dates of service.

(c) When making a DSH classification under (d) of this section, the department will use the following data sources as applicable: (1) for determination of Medicaid covered inpatient days, Medicaid charges, Medicaid payments, and Medicaid non-covered inpatient days, the MR-0-14 report for the qualifying year that is available at least six months after the end of the hospital’s fiscal year at the time the calculation is performed; (2) for determination and calculation of total hospital allowable costs, total inpatient hospital costs, Medicaid allowable costs, and physician costs, the Medicare cost report filed for the qualifying year and forms required by (b)(4)(A) of this section; (3) for total hospital days, total hospital revenues, cash subsidies, and patient revenues, the forms required by (b)(4)(B) of this section; (4) the log required by (b)(4)(C) of this section; (5) if the department determines that a piece of data or a data source listed in (1) - (4) of this subsection is unavailable, an alternate data source that the department determines to include the same information as the sources in (1) - (4) of this subsection. (d) A qualifying hospital may receive disproportionate share payments allocated to one or more of the following DSH classifications, if that hospital meets any additional criteria applicable to that classification, and subject to the limitations set out in (g) of this section: (1) payments allocated to each Medicaid inpatient utilization DSH (MIU DSH), if the qualifying hospital has a state Medicaid inpatient utilization rate at least one standard deviation above the mean of state Medicaid inpatient utilization rates for all hospitals in this state; the department will make a pediatric outlier payment, as necessary, in the manner specified in (e) and (f) of this section; for purposes of this paragraph,


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(A) the state Medicaid inpatient utilization rate is a fraction, expressed as a percentage, of which the numerator is the hospital’s number of Medicaid-eligible inpatient days in this state for the hospital’s qualifying year and the denominator is the total number of the hospital’s inpatient days for its qualifying year; and (B) the mean of Medicaid inpatient utilization rates for all hospitals in the state is the fraction, expressed as a percentage, of which the numerator is the total number of Medicaid-eligible inpatient days for all hospitals in this state for their qualifying year and the denominator is the total number of inpatient days for all hospitals in this state for their qualifying year;

(2) payments allocated to each low-income DSH (LI DSH), if the qualifying hospital has a low-income utilization rate exceeding 25 percent; the department will make a pediatric outlier payment, as necessary, in the manner specified in (e) and (f) of this section; for purposes of this paragraph, the low-income utilization rate is calculated as the sum of

(A) the fraction, expressed as a percentage, of which the numerator is the sum of the total Medicaid hospital revenue paid to the qualifying hospital for patient services provided to Medicaid-eligible patients in this state in the hospital’s qualifying year and the amount of cash subsidies received directly from the state or from local governments for patient services provided in this state in the hospital’s qualifying year, and the denominator is the total amount of hospital revenue for services, including the amount of cash subsidies specified in this subparagraph for that hospital’s qualifying year; and (B) the fraction, expressed as a percentage, of which the numerator is the total amount of the qualifying hospital’s charges for inpatient hospital services attributable to charity care for the hospital’s qualifying year, less the portion of any cash subsidies received directly from the state or from local governments for inpatient hospital services, and the denominator is the total amount of the hospital’s charges for inpatient services for the hospital’s qualifying year; for a state-owned qualifying hospital that does not have a charge structure, the hospital’s charges for charity care are equal to the cash subsidies received by the hospital from the state or from local governments;

(3) payments allocated to each single-point-of-entry psychiatric DSH (SPEP DSH), if the qualifying hospital

(A) enters into an agreement with the department to provide single-point-of-entry psychiatric services and complies with the requirements of that agreement; and (B) no more than 60 days after the end of each payment year, provides documentation to the department of the qualifying patients as defined in the agreement made under (A) of this paragraph; that documentation must include the number of encounters, the crisis category, the diagnosis at discharge, the provider and location of referral after discharge, and payment source information;

(4) payments allocated to each designated evaluation and treatment DSH (DET DSH), if the qualifying hospital

(A) is designated as an evaluation and treatment facility as required by 7 AAC 72;


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(B) enters into an agreement with the department to provide designated evaluation and treatment services and complies with the requirements of that agreement; and (C) no more than 60 days after the end of each payment year, provides documentation to the department of the qualifying patients as defined in the agreement made under (B) of this paragraph; that documentation must include the number of encounters, the crisis category, the diagnosis at discharge, the provider and location of referral after discharge, and payment source information;

(5) payments allocated to each institution for mental disease DSH (IMD DSH), if the IMD has been designated under 7 AAC 72 to receive involuntary commitments under AS 47.30.700 - 47.30.815; (6) payments allocated to each children’s medical care DSH (CMC DSH), if the qualifying hospital

(A) enters into an agreement with the department for medical and hospital care expenses for children in custody who are not Medicaid-eligible, and complies with the requirements of that agreement; and (B) no more than 60 days after the end of each payment year, provides documentation to the department of the qualifying patients as defined in the agreement made under (A) of this paragraph; that documentation must include the number of encounters;

(7) payments allocated to each institutional community health care DSH (ICHC DSH), if the qualifying hospital

(A) enters into an agreement with the department for medical and hospital care expenses for individuals in institutions who are not Medicaid-eligible, and complies with the requirements of that agreement; and (B) no more than 60 days after the end of each payment year, provides documentation to the department of the qualifying patients as defined in the agreement made under (A) of this paragraph; that documentation must include the number of encounters;

(8) payments allocated to each rural hospital clinic assistance DSH (RHCA DSH), if the qualifying hospital

(A) enters into an agreement with the department to provide support services to a clinic; the support services that the hospital provides must include

(i) services by hospital professional employees at the clinic site; the hospital may include, as services, the services of a primary care provider, nurse midwife services, obstetrical services, and pediatrician’s services; and (ii) assistance in arranging safe transport for those who require emergency transport and services;

(B) complies with the requirements of the agreement made under (A) of this paragraph; and (C) no more than 60 days after the end of each payment year, provides documentation to the department of the qualifying patients as defined in the agreement made under (A) of this paragraph; that documentation must include the number of encounters that the hospital provided at the clinic, and the support


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services as described in (A)(i) and (ii) of this paragraph; (9) payments allocated to each remainder of government allocation DSH (ROGA DSH), if

(A) after disproportionate share payments, if any, have been determined for each classification under (1) - (8) and (10) and (11) of this subsection, the qualifying hospital has a balance remaining within its facility-specific limit, as calculated under (g)(3) of this section; (B) the qualifying hospital is

(i) a public facility and enters into an agreement with the department to make an intergovernmental transfer to the department; or (ii) not a public facility, and enters into an agreement with the department and with either a public facility or a local government for the benefit of a public facility, in which the public facility or local government agrees to make an intergovernmental transfer to the department;

(C) any transfer of money that facilitates an intergovernmental transfer under (B)(ii) of this paragraph, and that occurs between the qualifying hospital and a public facility or local government that is party to an agreement under (B)(ii) of this paragraph, constitutes a valid exchange for value; and (D) the intergovernmental transfer required under (B) of this paragraph

(i) occurs no more than 96 hours after the qualifying hospital’s receipt of the disproportionate share payment under this paragraph; (ii) occurs by electronic transfer or paper transfer to the account designated by the department; and (iii) is done directly by the qualifying hospital acting as a government entity or through the recognized finance officer of the government entity;

(10) payments allocated to each mental health clinic assistance DSH (MHCA DSH), if the qualifying hospital

(A) enters into an agreement with the department to provide mental health services to a mental health clinic; (B) complies with the requirements of the agreement made under (A) of this paragraph; and (C) no more than 60 days after the end of each payment year, provides documentation to the department of the qualifying patients as defined in the agreement made under (A) of this paragraph; that documentation must include the number of mental health encounters that the hospital provided at the mental health clinic;

(11) payments allocated to each substance abuse treatment provider DSH (SATP DSH), if the qualifying hospital

(A) enters into an agreement with the department to provide substance abuse treatment services to a substance abuse treatment provider; (B) complies with the requirements of the agreement made under (A) of this paragraph; and


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(C) no more than 60 days after the end of each payment year, provides documentation to the department of the qualifying patients as defined in the agreement made under (A) of this paragraph; that documentation must include the number of substance abuse treatment encounters that the hospital provided through the substance abuse treatment provider.

(e) For the classifications in (d)(1) and (2) of this section, the department will make an annual pediatric outlier payment in the disproportionate share payment, if the hospital (1) provides inpatient hospital services not excluded under 7 AAC 105.110

(A) to a Medicaid patient who is under six years of age at the time of admission; and (B) that involve exceptionally long stays per admission in the qualifying year or exceptionally high costs per admission in the qualifying year; an exceptionally long stay per admission is a length of stay that is 150 percent or more of the length of stay of an average admission for the hospital, calculated as the hospital’s total inpatient days for the qualifying year for all children under six years of age divided by the hospital’s total admissions of all children under six years of age for the qualifying year; exceptionally high costs per admission are inpatient costs exceeding 150 percent of the hospital’s average inpatient costs, calculated as the hospital’s total inpatient costs for all children under six years of age in the hospital’s qualifying year divided by the hospital’s total admissions of all children under six years of age for the hospital’s qualifying year; inpatient costs for all children under six years of age are calculated by using the total inpatient hospital costs divided by the total inpatient hospital charges and multiplied by the charges for all children under six years of age; and

(2) submits to the department supporting documentation that includes a qualifying year log for all children admitted under six years of age, specifying charges, admissions, patient days, payments made for services, dates of service, and also documentation specifying total hospital admissions, charges, patient days, and payments made for services; information provided in this log must be accurate, complete, and in sufficient detail to be capable of verification by the department. (f) The pediatric outlier payment described in (e) of this section will be divided proportionately among the qualifying hospitals as calculated by the department based upon the number of inpatient days for children under six years of age who qualify. (g) The department will determine, as of the qualification date, a hospital’s eligibility for additional Medicaid payments under each classification in (d) of this section for the hospital’s qualifying year, in the following manner: (1) for the MIU or LI DSH classification, a disproportionate share payment to each qualifying hospital will be made annually; for any other DSH classification, a disproportionate share payment to each qualifying hospital will be made in accordance with the agreement required for that classification; (2) a disproportionate share payment is subject to the availability of appropriations from the legislature; (3) the total annual disproportionate share payment for each qualifying hospital is subject to a facility-specific limit calculated under this paragraph; for the


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hospital’s qualifying year, the limit is the cost of services provided to Medicaid patients, less the amount paid to the hospital under provisions of this chapter other than this section, plus the cost of services provided to patients without health insurance or another source of third-party payments that applied to services rendered during the qualifying year, less any payments made by those patients without insurance or another source of third-party payment for those services; the hospital’s cost of services for this calculation is the total hospital allowable costs, as determined in 7 AAC 150.160 and 7 AAC 150.170, divided by the hospital’s total adjusted inpatient days; this result is multiplied by the total of the hospital’s adjusted inpatient days not covered by insurance or third-party payment and Medicaid adjusted inpatient days; the cost of services includes the cost of excluded services under an insurance policy; the cost of services does not include amounts that were not paid to the hospital by the patient’s health insurance or other source of third-party payments because of per diem maximums, coverage limitations, or unpaid patient co-payments or deductibles; for purposes of this paragraph, third-party payments do not include state payments to hospitals paid under 7 AAC 47 (general relief medical assistance) or 7 AAC 48.500 - 7 AAC 48.900 (chronic and acute medical assistance); (4) a disproportionate share payment is not subject to the payment limitations in 7 AAC 150.160(b)(8), (c)(3), or (k); (5) the disproportionate share payment is not used in calculating the hospital’s future years’ Medicaid payment rates or future disproportionate share payments; (6) in addition to the general facility-specific limit set out in (3) of this subsection, the total disproportionate share payment amount to institutions for mental disease (IMDs) may not exceed the federal IMD disproportionate share cap in effect for the applicable fiscal year; by the qualification date each year, the department will prepare an estimate of the federal IMD disproportionate share allotment to the state and compare that estimate with the department’s estimated total payment amounts to the qualifying hospitals under this section for the next federal fiscal year; if the department’s estimated total payment amounts exceed the department’s estimate of the federal IMD disproportionate share allotment, the disproportionate share payment amounts to each qualifying hospital for the next federal fiscal year will be adjusted downward on a prorated basis until the total amount of the disproportionate share payments for all qualifying hospitals combined is equal to the total federal IMD disproportionate share allotment to the state for the next federal fiscal year; the federal IMD disproportionate share allotment is subject to recalculation, reallocation, and recoupment, as set out in (1) of this section for the disproportionate share allotment; (7) the department will allocate 100 percent of the federal disproportionate share hospital allotment as follows:

(A) for the IMD DSH classification, the department will distribute the maximum allowed under the federal IMD disproportionate share cap and the federal IMD disproportionate share allotment; (B) the department will allocate to the MIU DSH classification one percent of the remaining disproportionate share allotment after the allocation to the IMD DSH classification is determined; (C) the department will allocate to the LI DSH classification one


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percent of the remaining disproportionate share allotment after the allocation to the IMD DSH classification is determined; (D) the department will allocate to the pediatric outlier payment for the MIU DSH and LI DSH classifications one-half of one percent of the remaining disproportionate share allotment after the IMD DSH classification is determined; (E) the department will allocate to the SPEP DSH classification at least one percent but no more than 20 percent of the remaining disproportionate share allotment after deducting the allocation under (A) - (D) of this paragraph; (F) the department will allocate to the DET DSH classification at least one percent but no more than 30 percent of the remaining disproportionate share allotment after deducting the allocation under (A) - (D) of this paragraph; (G) the department may allocate to the CMC DSH classification from zero to 20 percent of the remaining disproportionate share allotment after deducting the allocation under (A) - (F) of this paragraph; (H) the department may allocate to the ICHC DSH classification from zero to 10 percent of the remaining disproportionate share allotment after deducting the allocation under (A) - (F) of this paragraph; (I) the department may allocate to the RHCA DSH classification from zero to 35 percent of the remaining disproportionate share allotment after deducting the allocation under (A) - (F) of this paragraph; (J) each disproportionate share payment for the MIU DSH classification will be calculated based on the qualifying hospital’s SDM, divided by the sum of the SDMs of all qualifying MIU DSHs in the qualifying year; the resulting percentage will be multiplied by the allocation amount calculated in (B) of this paragraph; (K) each disproportionate share payment for the LI DSH classification will be calculated based on the qualifying hospital’s LUR, divided by the sum of the LURs of all qualifying LI DSHs in the qualifying year; the resulting percentage will be multiplied by the allocation amount calculated in (C) of this paragraph; (L) each disproportionate share payment for the SPEP DSH, DET DSH, CMC DSH, ICHC DSH, RHCA DSH, MHCA DSH, and SATP DSH classifications will be calculated within each classification based on the number of encounters to be performed by the qualifying hospital for that classification, as specified in the agreement required for that classification, divided by the total number of encounters to be performed by all qualifying hospitals within that classification, as specified in the agreements required for that classification; the resulting percentage will be multiplied by the allocation amount applicable to that classification, as calculated in (E) - (I) and (O) and (P) of this paragraph; (M) the amount of disproportionate share payments to qualifying hospitals under the ROGA DSH classification will be determined and calculated

(i) to reflect the facility-specific limits established under (3) of this subsection for each hospital; and (ii) proportionately to reflect remaining available disproportionate share money after calculation of the payments for the


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classifications in (d)(1) - (8) and (10) and (11) of this section; (N) for disproportionate share payments to a qualifying hospital under the ROGA DSH classification, the department will allocate the lesser of

(i) the amount of those payments that the qualifying hospital has requested; and (ii) a proportionate amount calculated, as a percentage, in which the numerator is the amount of those payments that the qualifying hospital has requested and the denominator is the sum of all disproportionate share payments to all qualifying hospitals within the ROGA DSH classification;

(O) the department may allocate to the MHCA DSH classification from zero to 35 percent of the remaining disproportionate share allotment after deducting the allocation under (A) - (F) of this paragraph; (P) the department may allocate to the SATP DSH classification from zero to 15 percent of the remaining disproportionate share allotment after deducting the allocation under (A) - (F) of this paragraph; (Q) the department may allocate a percentage greater than the maximum percentage in (E) - (I) and (O) and (P) of this paragraph only if the combined allocation under (E) - (I) and (O) and (P) of this paragraph does not exceed 100 percent of the remaining disproportionate share allotment after deducting the allocation under (A) - (D) of this paragraph and the department determines that the final allocation among all classifications will promote the availability of efficient and economic access to health care services; in making that determination, the department will consider these factors:

(i) the distribution of medical services and resources in the communities of the state; (ii) the availability of health services to the general population in the same geographic area.

(h) The department will make to each qualifying hospital within the MIU DSH classification and to each qualifying hospital within the LI DSH classification a minimum payment of $10,000 per payment year and per classification, subject to the facility-specific limit calculated under (g)(3) of this section, the federal IMD disproportionate share cap in effect for the next federal fiscal year, and the amount of appropriations from the legislature. During a payment year, the department will not make total annual disproportionate share payments that exceed the total amount allowed under the state’s federal disproportionate share allotment for the applicable federal fiscal years. On or before the qualification date, the department will send to each hospital a list of the qualifying hospitals and the amount of the payments for the upcoming payment year. The department’s determination under this subsection is the department’s final administrative action, unless a request for reconsideration is filed (1) under (i) of this section, regarding whether a hospital is a qualifying hospital; or (2) under (j) of this section, regarding the amount of a qualifying hospital’s disproportionate share payment under this section. (i) A hospital aggrieved by the department’s decision under (h)(1) of this section may request reconsideration of the decision by filing a request for reconsideration with


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the department, and sending a copy of the request to each qualifying hospital, no more than 10 days after the date of the department’s list under (h)(1) of this section. The request for reconsideration must state the facts in the record that support a reversal of the initial decision. A qualifying hospital to which a request for reconsideration was sent may file with the department, no more than 10 days after the date the request was sent, a response to the request for reconsideration. The response must be based on facts in the record. The department’s decision on reconsideration is the department’s final administrative action on a reconsideration request under this subsection. If the department does not issue a decision on reconsideration 30 days or less after the deadline for filing a response to the request for reconsideration, and if the department does not waive the 30-day deadline, the request is considered denied by the department. The denial is the department’s final administrative action on a reconsideration request under this subsection. (j) A qualifying hospital aggrieved by the department’s determination under (h)(2) of this section may request reconsideration of the determination by filing a request for reconsideration, and sending the request to the other qualifying hospitals, no more than 10 days after the date of the department’s list of amounts under (h) of this section. If the department has made the disproportionate share payment under this section to the qualifying hospital, the department will accept and consider a request for reconsideration under this subsection only after any intergovernmental transfer of money required by (d)(9) of this section is made. A request for reconsideration under this subsection must state the facts in the record supporting a change in the payment amount. A qualifying hospital to which a request for reconsideration was sent may file with the department, no more than 10 days after the date the request was sent, a response to the request for reconsideration; the response must be based on facts in the record. The department’s decision on reconsideration is the department’s final administrative action on a reconsideration request under this subsection. If the department does not issue a decision on reconsideration 30 days or less after the deadline for filing a response to the request for reconsideration, and does not waive the 30-day deadline, the request is considered denied by the department. The denial is the department’s final administrative action on a reconsideration request under this subsection. (k) The administrative appeal process provided by 7 AAC 150.220 and the exceptional relief process set out in 7 AAC 150.240 are not available to a hospital disputing an item on the department’s list under (h) of this section of qualifying hospitals and amounts. (l) The department will recalculate and reallocate the disproportionate share eligibility and payments for all hospitals and will recoup payments from all hospitals on a prorated basis if the (1) disproportionate share eligibility and payment for any hospital will be recalculated as a result of a decision under (i) or (j) of this section or of a court decision; or (2) outcome of a decision under (i) or (j) of this section or of a court decision would cause the total disproportionate share payments to exceed the federal allotment for the federal fiscal year in which the payment rate was in effect. (m) In this section, unless the context otherwise requires, (1) "adjusted inpatient days" means patient days calculated as the product


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of patient days multiplied by total hospital inpatient and outpatient charges divided by hospital inpatient charges; (2) "admission" means admission to a hospital for inpatient care; (3) "cash subsidies" does not include money generated under the public hospital proportionate share payment under 7 AAC 150.100; (4) "encounter" means a unit of service, visit, or face-to-face contact that is a covered service under an agreement with the department as required under (d)(3), (4), (6), (7), (8), (10), or (11) of this section; (5) "inpatient days" means patient days at licensed hospitals that are calculated

(A) to include patient days related to a hospitalization for acute treatment of the following:

(i) injured, disabled, or sick patients; (ii) substance abuse patients who are hospitalized for substance abuse detoxification; (iii) swing-bed patients whose hospital level of care is reduced to nursing facility level without a physical move of the patient; (iv) patients hospitalized for rehabilitation services for the rehabilitation of injured, disabled, or sick persons; (v) patients in a hospital receiving psychiatric services for the diagnosis and treatment of mental illness; (vi) newborn infants in hospital nurseries; and

(B) not to include patient days related to the treatment of patients (i) at licensed nursing facilities; (ii) in a residential treatment bed; (iii) on a leave of absence from a hospital beginning with the day the patient begins a leave of absence; (iv) who are in a hospital for observation to determine the need for inpatient admission; or (v) who receive services at a hospital during the day but are not housed there at midnight;

(6) "Medicaid-eligible inpatient days" means patient days at licensed hospitals that are calculated

(A) to include Medicaid-covered and Medicaid-noncovered days related to a hospitalization for acute treatment of the following:

(i) injured, disabled, or sick patients; (ii) substance abuse patients who are hospitalized for substance abuse detoxification; (iii) swing-bed patients whose hospital level of care is reduced to nursing facility level without a physical move of the patient; (iv) patients hospitalized for rehabilitation services for the rehabilitation of injured, disabled, or sick persons; (v) patients in a hospital receiving psychiatric services for the diagnosis and treatment of mental illness; (vi) newborn infants in hospital nurseries; and

(B) not to include Medicaid covered and Medicaid non-covered


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patient days related to the treatment of patients (i) at licensed nursing facilities; (ii) in a residential treatment bed; (iii) on a leave of absence from a hospital beginning with the day the patient begins a leave of absence; (iv) who are in a hospital for observation to determine the need for inpatient admission; or (v) who receive services at a hospital during the day but are not housed there at midnight;

(7) "payment year" means the state fiscal year; (8) "qualification date" means July 1 of each year; (9) "qualifying hospital" means a hospital that qualifies as a DSH under this section; (10) "qualifying year" means the hospital’s fiscal year ending

(A) at least 11 but no more than 37 months before the beginning of the state fiscal year in which the disproportionate share payment is made; and (B) within the most recent 12-month reporting cycle in which all facilities have filed a complete year-end report with the department. (Eff. 2/1/2010, Register 193)

Authority: AS 47.05.010 AS 47.07.070 AS 47.07.073 Editor’s note: The mailing address for sending documentation required under 7 AAC 150.180, and for filing requests for reconsideration under 7 AAC 150.180, is the Department of Health and Social Services, DSH Program, P.O. Box 110660, Juneau, Alaska 99811-0660. 7 AAC 150.190. Optional payment rate methodology and criteria for small facilities. (a) The provisions of this section apply to a small facility that (1) had 4,000 or fewer acute care patient days at an general acute care, specialty, or inpatient psychiatric hospital or at a combined general acute care hospital-nursing facility or had 15,000 or fewer Medicaid nursing facility days at a nursing facility that is not combined with a general acute care hospital during the small facility’s fiscal year that ended 12 months before the beginning of the prospective year; and (2) elects to participate in rate setting under (c) of this section. (b) The department will use the methodology and criteria set out in this section to review and set prospective payment rates for a small facility that elects rate setting under (c) of this section. (c) A small facility without a rate agreement may not elect to participate in a rate agreement under (d) of this section until after a re-basing occurs under 7 AAC 150.160. A small facility that does not elect to participate in a new rate agreement after a rate agreement expires may not elect to participate in a rate agreement under (d) of this section until after a re-basing occurs under 7 AAC 150.160. A small facility that elects to participate in rate setting under this section must (1) make an affirmative election to do so; and (2) notify the department staff that oversees Medicaid payment rates of the facility’s election on the written notification form provided by the department under this section and return the form to the department staff that oversees Medicaid payment rates no later than 30 days after the date of the department’s mailing of the notification.


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(d) The department will not establish prospective payment rates under this section for a small facility unless the (1) small facility enters into a rate agreement with the department that contains at least the following terms:

(A) the rate agreement between the department and the small facility may not expire or lapse before four facility fiscal years have elapsed; (B) the small facility may not revoke its election to participate in rate setting under this section until after the last day of the small facility’s fourth fiscal year; and

(2) department determines that the rate agreement does not conflict with the public concern that needy persons in the state receive uniform and high quality medical care; factors that the department will consider in making that determination include

(A) the distribution of medical services and resources in the communities of the state; and (B) whether during the term of the rate agreement, appropriations to the department are expected to be available in amounts adequate to pay the Medicaid rates proposed in the small facility rate agreement.

(e) A prospective payment rate established under this section is not subject to 7 AAC 150.220, except as provided by (k) of this section and is not subject to 7 AAC 150.150. (f) Except as otherwise specified under (l) of this section, the department will base the small facility prospective payment rate for a rate agreement made under (d) of this section on the rate calculated under 7 AAC 150.160 after the election of the small facility is exercised under (c) of this section. For the eligible small facilities’ fiscal year beginning in calendar year 2003, each small facility may (1) terminate its current small facility rate agreement and enter into a new rate agreement in which the prospective payment rate is based on the rate calculated under 7 AAC 150.160, using fiscal year 2000 as the base year for facilities whose fiscal year ends on December 31, and using fiscal year 2001 as the base year for all other facilities; or (2) enter into a rate agreement in which the prospective payment rate based on the rate calculated under 7 AAC 150.160, using fiscal year 2000 as the base year for facilities whose fiscal year ends on December 31, and using fiscal year 2001 as the base year for all other facilities. (g) The first year payment rate established under a rate agreement made under (d) of this section will be calculated as follows, except that the adjustment factors identified in 7 AAC 150.150 will not be applied: (1) the first year payment rate for inpatient acute care services will be expressed as a per-day rate calculated under 7 AAC 150.160(b); for each complete fiscal year of the small facility that begins during the period after the first payment year of the rate agreement made under (d) of this section and that ends at the expiration of the rate agreement, the first year payment rate will be increased by updating the noncapital portion of the payment rate annually at the rate of three percent per year and by updating the capital portion of the payment rate annually at the rate of 1.1 percent per year; (2) a prospective payment rate for all outpatient acute care services will


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be expressed as the percentage of charges component calculated under 7 AAC 150.160(c); (3) a first year payment rate for long-term care will be expressed as a per-day rate as calculated in 7 AAC 150.160(e); for each complete fiscal year of the small facility that begins during the period after the first payment year of the rate agreement made under (d) of this section and that ends at the expiration of the rate agreement, the first year payment rate will be increased by updating the noncapital portion of the payment rate annually at the rate of three percent per year and by updating the capital portion of the payment rate annually at the rate of 1.1 percent per year; (4) the department will allow an increase in the capital component under (1) or (3) of this subsection of the prospective payment rate for new assets that the small facility places in service after its base year as set out in 7 AAC 150.160(f), if

(A) the assets that are placed in service by the small facility have a value of at least $5,000,000; (B) the small facility obtains one or more certificates of need for the assets that will be placed in service; and (C) no later than 60 days before the effective date of the increase in the prospective payment rate for the small facility, the small facility provides to the department a detailed capital budget in accordance with 7 AAC 150.130(b) that reflects the allowance for the new assets that have been placed in service.

(h) Notwithstanding (g) of this section, the prospective per-day payment rate established for a small facility may not exceed the charges made by the small facility. The charges will be compared in the aggregate. (i) If, after execution of a rate agreement made under (d) of this section, federal or state law mandates a change to a prospective payment rate, the department will consider recommendations made by the small facility before amending the prospective payment rate for the small facility. (j) If a small facility elects rate setting under this section, the reporting requirements of 7 AAC 150.130 and 7 AAC 150.140 that are applicable to the small facility during the rate agreement period under (d) of this section are modified as follows: (1) the small facility shall submit the Medicare cost report and forms YET-1, T-2, SS-1A, SS-1B, and SS-1C of the required financial reporting forms from the Medicaid Hospital and Long-Term Care Facility Reporting Manual, adopted by reference in 7 AAC 160.900; (2) except if the small facility requests a prospective payment rate adjustment for new assets under (g)(4) of this section, the small facility is not required to submit the budget report; (3) in place of the audited financial statement, the small facility may submit a review of the small facility’s financial statements; the department will accept the review that is submitted if the review

(A) was conducted by an independent certified public accountant; and (B) includes the balance sheet and related statements of income, retained earnings, and cash flows in accordance with the Statement on Standards for Accounting and Review Services No. 7 (1992) issued by the American Institute of Certified Public Accountants.


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(k) If a small facility elects rate setting under this section, (1) except as otherwise specifically provided in (2) of this subsection, the exceptional relief process set out in 7 AAC 150.240 is the sole administrative review and appeals process available to a small facility; and (2) small facility use of the administrative appeal provisions of 7 AAC 150.220 is limited to appeal of an action or decision of the department that relates to

(A) the small facility’s eligibility to elect rate setting under this section; (B) the violation of a term of the rate agreement made under (d) of this section; or (C) denial of an increase in the prospective payment rate based on a determination made under (g)(4) of this section.

(l) A small facility general acute care hospital may elect a new four-year rate agreement under (d) of this section if the facility becomes a combined general acute care hospital-nursing facility. The combined facility may choose this option no more than 30 days after the combination of the two facilities. The payment rate changes become effective the date the facilities combine and will be calculated as follows: (1) the small facility acute care per-day rate and the nursing facility per-day rate will be calculated at the statewide weighted average of the payment rates in effect for small facilities qualified under (a) of this section as of the date the facilities combine; (2) the outpatient acute care percentage rate will be calculated as the statewide average of the outpatient payment rates in effect for all qualified general acute care hospital small facilities as of the date the facilities combine. (m) A rate agreement made under (d) of this section may be renewed if the small facility still qualifies under this section. The department will perform a re-basing in accordance with 7 AAC 150.160 for rates for renewed rate agreements established under this section. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.071 AS 47.07.073 AS 47.07.070 Editor’s note: The address for filing notifications under 7 AAC 150.190 is Department of Health and Social Services, Office of Rate Review, 3601 C Street, Suite 978, Anchorage, Alaska 99503. 7 AAC 150.200. Facility audits and desk reviews. (a) In administering the Medicaid program, the department may perform facility audits, desk reviews, and field audits of various types and scope and take the results of those facility audits, desk reviews, and field audits into account in establishing a facility’s payment rate. The department will perform facility audits, desk reviews, and field audits with respect to a facility’s year-end report submitted under 7 AAC 150.130(c). The scope and frequency of facility audits, field audits, and desk reviews are determined at the department’s discretion. This section does not apply to the department’s conduct of investigations or audits regarding patient abuse or neglect, fraud, or other program noncompliance. This section does not limit the department’s authority under this chapter to review and adjust items directly included in a facility’s payment rate based on a budget submitted under 7 AAC 150.130(b).


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(b) If the department performs a field audit or desk review, the process in this subsection applies. The department will commence its field audit or desk review with respect to a facility’s year-end report after the facility has filed its year-end report under 7 AAC 150.130(c) and the department has determined the report to be complete under 7 AAC 150.140(e). The department will review the facility’s year-end report and provide written notice in accordance with 7 AAC 150.140(a) - (d). The department will complete its field audit or desk review of a facility’s year-end report and provide to the facility a completed field audit or desk review report. The department will provide to the facility, as attachments to the department’s completed report, a revised Medicare cost report, and a revised Medicare cost report in electronic format if the facility provided a CMS-approved electronic filing of its Medicare cost report with its annual year-end report. The department will provide the department’s completed report and all attachments to the facility promptly upon completion, in accordance with (1) or (2) of this subsection, or (f) of this section. The following provisions apply to year-end field audit and desk review reports: (1) if a facility’s year-end report required by 7 AAC 150.130(c) is filed with the department no more than 150 days after the close of the facility’s fiscal year and is determined by the department to be complete, the department will provide to the facility a completed report and the department’s proposed adjustments to the year-end report for purposes of setting rates under this chapter no later than 40 days before the beginning of the facility’s applicable rate year; (2) if the facility’s year-end report required by 7 AAC 150.130(c) is filed with the department more than 150 days after the close of the facility’s fiscal year, the department may establish a temporary rate for the facility pending establishment of the facility’s permanent rate; (3) a facility may file with the department a response to the department’s field audit or desk review report no more than 40 days after the date the department issues the report; the department may make additional related adjustments if the facility makes objections to the department’s adjustments; the department will provide to the facility a description of any additional adjustments; (4) adjustments proposed during the course of a desk review or a field audit are not limited to adjustments the department has made in prior desk reviews or audits; the department may make adjustments to reflect reporting in accordance with AS 47.07 and 7 AAC 105 - 7 AAC 160. (c) The department may conduct desk reviews or field audits of a facility. The department may conduct a field audit with respect to a facility’s year-end report submitted under 7 AAC 150.130(c) or expand the desk review to a field audit. During a department desk review or field audit, the department may review a sample of medical and billing records for both Medicaid and non-Medicaid patients in order to determine that the Medicaid program is being charged no more than any other payer types for the same services. (d) The department may limit its review of a facility to a desk review. The department is not required to conduct a desk review in accordance with the auditing standards applicable to field audits. As part of a desk review, the department may submit requests for documents or production of other items, as well as requests for information or responses to specific questions. A facility will be allowed at least 15 days, but not


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more than 45 days, including extensions, to provide the department with its response to the requests, as measured from the date that the department mailed or otherwise forwarded the requests to the facility. A facility’s failure to timely respond to the department’s requests as provided for in this subsection may result in permanent disallowance of the items in question. This section does not limit the right of a facility to appeal adjustments under 7 AAC 150.220. (e) The department may conduct a field audit of a facility. The department’s field audits will be conducted in accordance with the Government Auditing Standards established by the comptroller general of the United States, adopted by reference in 7 AAC 160.900. In conducting a field audit, the following procedures govern: (1) the department will notify the facility at least 20 days in advance of any field work scheduled at the facility; the notification will state the planned areas of emphasis and describe documents, items, or other information that the facility is required to produce at the entrance conference; this requirement does not limit the department’s authority to modify the audit or to require additional information that the department considers necessary; the notification will include a proposed agenda for the entrance conference; (2) the department will schedule an entrance conference with the facility at the earliest practicable time during the audit; at the entrance conference, the department may discuss all proposed adjustments identified to date, will designate the auditor in charge of conducting the audit on behalf of the department, and will address necessary administrative issues relating to the audit; at the entrance conference, the facility shall have all materials requested in the notification of the field audit available for the auditor, designate the person who will act as liaison on behalf of the facility for all purposes with respect to the audit, address the availability of third parties involved in preparation of the information being audited, and address other issues relating to the conduct of the audit; (3) the timelines established for a facility’s response to the department’s requests for documents and other information relating to desk reviews also apply to field audits, except for requests made by the auditor while at the facility in the conduct of a field audit; while the department is at a facility conducting a field audit, the facility shall promptly respond to the auditor’s requests to produce documents or other items, and to requests for information during normal working hours; (4) the department will work with the facility to schedule the auditor/facility liaison consultations that are necessary to discuss proposed audit adjustments, open issues, and general progress of the audit; (5) an exit conference shall be conducted as audit work at the facility nears completion unless the facility requests the department in writing not to conduct an exit conference; the department’s auditor and the facility’s representatives authorized to respond to audit questions shall attend the exit conference; third-party preparers of reports or statements subject to audit and other facility consultants may also attend an exit conference; at an exit conference, the department will provide the facility with all audit adjustments that have been made final by that time, discuss unresolved issues, and indicate what type of information is required from the facility to resolve those issues; the department may make additional findings and adjustments during preparation of the audit report;


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(6) a facility shall, no more than 30 days after the date of the exit conference, provide documents or other items not available at the exit conference and its comments relating to the department’s proposed audit adjustments; the auditor may, for good cause, extend the time for the facility to provide the documents or other items; (7) the department will review and consider the information provided by the facility and issue the audit report and adjustments that are proposed to be made for purposes of setting rates under this chapter; (8) a facility’s failure to timely respond to the department’s requests as provided in this subsection may result in permanent disallowance of the items in question; this paragraph does not limit the right of a facility to appeal adjustments under 7 AAC 150.220. (f) The department may conduct desk reviews or field audits of a facility at times later than otherwise provided for in this section. To the greatest extent practicable, the procedures described in this section apply to out-of-time desk reviews and field audits. The department may prospectively adjust a facility’s rates or other payments, taking into account the out-of-time desk review or field audit at the time of the facility’s next rate-setting for the rate year that begins at least 90 days after the department provides the completed report to the facility. In establishing a rate, the department is not required to consider or include adjustments made by Medicare intermediaries to Medicare cost reports after the department has completed its audit. The department will provide the facility with all adjustments proposed to be made for purposes of setting rates under this chapter and attachments specified in (b) of this section. (g) The report presented to the facility will include (1) criteria that form the basis of the adjustments, including the statutory, regulatory, or contractual bases of the criteria; (2) findings that state the facility’s noncompliance with applicable statutes, regulations, or contractual requirements, and that state calculation or reporting errors; (3) a revised year-end report if the report identifies changes that should be made in the year-end report; and (4) other findings as determined by the department. (h) A facility shall produce items to be desk-reviewed or audited by the department at a location within the state or at another place agreed upon by the department and the facility. (i) For purposes of this section, (1) "auditor" means the department’s officials, employees, contractors, agents, and any other person acting on the department’s behalf in conducting an audit of a facility; (2) "desk review" means the department’s review that is conducted without the auditor visiting the facility being desk-reviewed for the purpose of conducting tests or the initial phase of a field audit; (3) "facility" means the same entities listed in the definition of "facility" in 7 AAC 160.990 and includes all of a facility’s affiliated or otherwise related persons that possess documents or other information related to the entity that is subject to audits under this section; (4) "field audit" means the department’s audit that includes at least one


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facility visit by the auditor for the purpose of conducting audit tests; (5) "rate year" means the prospective payment year of a facility, based upon that facility’s fiscal year; (6) "facility audit" means a systematic inspection of accounting and statistical records of a facility, including analyses, tests, and confirmations. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.071 AS 47.07.074 AS 47.07.070

7 AAC 150.210. Procedure for establishment of rates. (a) Based on consideration of the documents submitted by the facility, audit or review of the facility and the facility’s responses to audit or review testimony at the public hearing, and the requirements of AS 47.07 and 7 AAC 105 - 7 AAC 160, the department staff that oversees Medicaid payment rates shall establish the prospective payment rate in a written determination and shall send a copy of the written determination to the facility. The written determination must be accompanied by a certificate showing the date of mailing to the facility. (b) The department staff that oversees Medicaid payment rates may reconsider a prospective payment rate upon the department staff’s own motion or at the facility’s request. A facility seeking reconsideration must file a request for reconsideration no more than 30 days after the date of mailing the written determination to the facility. The department staff shall deny a request for reconsideration as untimely if the request was not filed 30 days or less after the date of mailing the written determination to the facility. The notice of denial of reconsideration or the decision on reconsideration must be accompanied by a certificate showing the date of mailing to the facility. (c) A request for reconsideration under (b) of this section must be filed at the Anchorage office of the department with the staff that oversees Medicaid payment rates. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.070 Editor’s note: The address for filing requests for reconsideration under 7 AAC 150.210 is Department of Health and Social Services, Office of Rate Review, 3601 C Street, Suite 978, Anchorage, Alaska 99503. 7 AAC 150.220. Administrative appeal. (a) No more than 30 days after the date a written determination under 7 AAC 150.210(a) is mailed, a facility aggrieved by that determination may request reconsideration under 7 AAC 150.210(b) or may file a written notice of appeal with the commissioner. In the notice of appeal, the facility must (1) set out a statement of issues; (2) identify the basis for the facility’s contention that the written determination of the prospective payment rate is incorrect; (3) specify the relief requested; (4) provide a name, address, telephone number, and other contact information for the facility representative designated as the point of contact for the appeal; and (5) include a certificate of mailing. (b) If a request for reconsideration under 7 AAC 150.210(b) is denied, or if a


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facility is aggrieved by a decision on reconsideration under 7 AAC 150.210(b), the facility may file a written notice of appeal with the commissioner no more than 30 days after the date the denial or decision is mailed. In the notice of appeal, the facility must (1) set out a statement of issues; (2) identify the basis for the facility’s contention that the written determination of the prospective payment rate is incorrect; (3) specify the relief requested; (4) provide a name, address, telephone number, and other contact information for the facility representative designated as the point of contact for the appeal; and (5) include a certificate of mailing. (c) If a decision on a prospective payment rate is appealed to the commissioner, that rate will be effective subject to adjustment based on the commissioner’s decision on the administrative appeal. (d) A notice of appeal under (a) or (b) of this section must be filed at the office of the commissioner in Juneau, and a copy must be sent to the Anchorage office of the department with the staff that oversees Medicaid payment rates. (e) The commissioner will deny an administrative appeal as untimely if not filed within the time limits set out in this section. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.070 AS 47.07.075 Editor’s note: The address for filing of the original of a notice of appeal under 7 AAC 150.220(a) or (b) is Office of the Commissioner, Room 229, Alaska Office Building, P.O. Box 110601, Juneau, Alaska 99811-0601. The address for sending a request for reconsideration, or for sending copies described in 7 AAC 150.220(d) is Department of Health and Social Services, Office of Rate Review, 3601 C Street, Suite 978, Anchorage, Alaska 99503. 7 AAC 150.230. Appeal procedures. (a) If a notice of appeal satisfies the requirements of 7 AAC 150.220, the department will file, in accordance with the prehearing schedule established under (c) of this section, and with both the hearing officer and the facility representative designated under 7 AAC 150.220(a)(4) or (b)(4) as the point of contact, a written response setting out the department’s position with respect to each of the points raised in the appeal. In the response, the department will state clearly the defenses it intends to assert. (b) No more than 15 days after receiving a notice of appeal that satisfies the requirements of 7 AAC 150.220, the commissioner will assign the case to a hearing officer. The commissioner will send notice of the assignment to the assigned hearing officer, the department, and the facility representative designated under 7 AAC 150.220(a)(4) or (b)(4) as the point of contact. In the notice, the commissioner will state the date that the commissioner received the notice of appeal. The notice will be accompanied by a copy of the notice of appeal and any documents filed with the notice of appeal. (c) No more than 45 days after receiving the notice of assignment, the hearing officer shall conduct a prehearing conference, at which time a schedule shall be established that sets prehearing deadlines and a date for the hearing. The schedule shall provide for a hearing on the administrative appeal under 7 AAC 150.220(a) or (b) to begin no more than 120 days after the written notice of appeal was received by the


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commissioner, unless the facility requests a delay or the hearing officer finds good cause for the delay. The hearing officer may find good cause for the delay under AS 47.07.075(b)(1) and this subsection in circumstances such as the following: (1) the hearing officer finds that the facility waived its right to a timely hearing under this section; (2) the parties stipulated to the hearing being held at a later date; (3) the facility failed to file the statement of issues described in (a) of this section at the time that the notice of appeal was initially filed; (4) the facility amended its statement of issues after initial filing; (5) the hearing officer finds that strict adherence to the 120-day time limit for a hearing would work injustice. (d) A facility may amend its original statement of issues once as a matter of course at any time before the department’s response is filed. The department may amend its response to the facility’s statement of issues, once no more than 20 days after the department’s original response is filed. A party may amend the statement of issues or a response at other times only by leave of the hearing officer or by written consent of the opposing party. The hearing office shall freely grant leave to amend, if the hearing officer finds justice so requires. Unless the hearing officer orders otherwise, the department shall respond to an amended statement of issues no later than the time remaining for response to the original statement of issues or no more than 10 days after service of the amended statement of issues, whichever period is longer. (e) Unless otherwise ordered by the hearing officer, discovery shall be permitted in accordance with a plan for discovery approved by the hearing officer. (f) The hearing officer shall issue a proposed decision on the appeal no more than 180 days after the latest of the following events: (1) completion of briefing on a dispositive motion, or oral argument on the motion, whichever is later; (2) completion of the evidentiary hearing, including post-hearing briefing and argument, if any. (g) If a proposed decision is not issued under (f) of this section in 180 days or less, the hearing officer shall inform the commissioner and the parties, in writing, as to the reasons for the delay. Failure to complete a proposed decision in 180 days or less does not affect the status of the administrative proceeding or the rights of the parties in the administrative proceeding. (h) Unless otherwise specified by statute, regulation, or an order by the hearing officer, proceedings shall be conducted in accordance with the Alaska Rules of Civil Procedure. A party may file documents with the hearing officer by facsimile or other electronic means only if authorized by order of the hearing officer. (i) No more than 30 days after receiving the proposed decision of the hearing officer, the commissioner will issue a decision or refer the appeal back to a hearing officer for additional findings of fact or redetermination of the issues presented. The commissioner will provide copies of the commissioner’s decision to the (1) hearing officer; (2) facility representative designated under 7 AAC 150.220(a)(4) or (b)(4) as the point of contact; (3) department staff that oversees Medicaid payment rates; and


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(4) director of the division of the department responsible for paying Medicaid program claims. (j) In making the report on noncompliance with the 120-day hearing time limit as required by AS 47.07.075, the department will only include a hearing that did not comply with that time limit, if the time limit was not adjusted under (c) of this section. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.070 AS 47.07.075 7 AAC 150.240. Exceptional relief to prospective payment rate setting. (a) If application of the methodology in 7 AAC 145.700 or 7 AAC 150.040 - 7 AAC 150.190 results in a permanent prospective payment rate that does not allow reasonable access to quality patient care provided by an efficiently and economically managed facility, the facility may apply to the deputy commissioner for exceptional relief from the rate-setting methodology. (b) To apply for exceptional relief under (a) of this section, at a minimum the facility’s application must include (1) the amount by which the facility estimates that the prospective payment rate should be increased to allow reasonable access to quality patient care provided by an efficiently managed facility; (2) the reasons and the need for the exceptional relief requested, including any resolution by the facility’s governing body to support the reasons offered, and why such a rate increase cannot be obtained through the existing rate-setting regulations; (3) the description of management actions taken by the facility to respond to the situation on which the exceptional relief request is based; (4) the audited financial statement for the facility for the most recently completed facility fiscal year and financial data, including a statement of income and expenses, a statement of assets, liabilities, and equities, and a monthly facility cash flow analysis, for the fiscal year for which the exception is requested; (5) a detailed description of recent efforts by the facility to offset the deficiency by securing revenue sharing, charity or foundation contributions, or local community support; (6) an analysis of community needs for the service on which the exception request is based; (7) a detailed analysis of the options of the facility if the exception is denied by the deputy commissioner; (8) a plan for future action to respond to the problem; and (9) an analysis of how many Medicaid patients will lose access to Medicaid services available to the general public in the same geographic area if exceptional relief is not granted. (c) The facility shall provide other information requested by the deputy commissioner in order to evaluate the request. If a facility fails to supply the requested information within a reasonable period, the deputy commissioner may deny the request. (d) The deputy commissioner may use any information available in department records to evaluate the request. The deputy commissioner shall provide copies of the additional material to the facility upon request of the facility. (e) The deputy commissioner may increase the prospective payment rate, by all


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or part of the facility’s request, if the deputy commissioner finds by clear and convincing evidence that the rate established under the methodology in 7 AAC 145.700 or 7 AAC 150.040 - 7 AAC 150.190 does not allow for reasonable access to quality patient care provided by an efficiently and economically managed facility, and that the granting of an exception is in the public interest. In determining whether the exception is in the public interest, the deputy commissioner may consider at least (1) the necessity of the rate increase to allow reasonable access to quality care provided by an efficiently and economically managed facility, including any findings of the governing body of the facility to support the need; (2) the assessment of continued need for the facility’s services in the community; (3) whether the facility has taken effective steps to respond to the crisis and has adopted effective management strategies to alleviate or avoid the future need for exceptional relief; (4) whether Medicaid patients will lose access to Medicaid services available to the general public in the same geographic area if exceptional relief is not granted; (5) the availability of other resources available to the facility to respond to the crisis; (6) whether the relief from an exception should have been obtained under the existing rate methodology; and (7) other factors relevant to assess reasonable access to quality patient care provided by an efficiently and economically managed facility. (f) The deputy commissioner may impose conditions on the receipt of exceptional relief. Those conditions may include one or more of the following: (1) the facility sharing the cost of the prospective payment rate exception granted; (2) the facility taking effective steps in the future to alleviate the need for future requests for exceptional relief; (3) the facility providing documentation as specified by the deputy commissioner of the continued need for the exception; (4) a maximum amount of exceptional relief to be granted to this facility under this section. (g) If the deputy commissioner grants exceptional relief under this section, any amount granted may not be included as part of the base on which future prospective payment rates are determined. (h) Exceptional relief granted under this section is effective prospectively from the date of the exceptional relief decision, and for a period of time not to extend beyond the end of the facility’s rate-setting year. A facility may apply for exceptional relief in the following year by submitting a new application under (a) of this section. (i) Notwithstanding 7 AAC 150.220, a party aggrieved by a decision of the deputy commissioner concerning exceptional relief may, no more than 30 days after the date of mailing of the decision to that party, request an administrative hearing to the commissioner of the department. The commissioner will consider the request for appeal as untimely filed if the commissioner has not received the request 30 days or less after the deputy commissioner’s mailing of the notice of the decision to the party. The exceptional


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relief granted by the deputy commissioner will be effective subject to adjustment based on the decision reached by the commissioner on the appeal. A copy of the commissioner’s decision on appeal will be provided to the facility, to the deputy commissioner, and to the department staff that oversees Medicaid payment rates. (j) The deputy commissioner shall send copies of the decision of the deputy commissioner concerning exceptional relief to the facility, to the director of the division of the department responsible for paying Medicaid program claims, and to the department staff that oversees Medicaid payment rates. The exceptional relief decision shall be accompanied by a certificate showing the date of mailing to the persons listed in this subsection. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.073 AS 47.07.075 AS 47.07.070 7 AAC 150.990. Definitions. (a) In this chapter, (1) "adjusted Medicare cost report" means a base year’s Medicare cost report that has been adjusted in accordance with 7 AAC 150.170 or 7 AAC 150.200; (2) "assets" means all economic resources of a health facility, recognized and measured in conformity with generally accepted accounting principles; "assets" includes certain deferred charges that are not resources but that are recognized and measured in accordance with generally accepted accounting principles; (3) "audit" means the systematic inspection of accounting records involving analyses, tests, or confirmations; (4) "base year" means the facility’s fiscal year ending 12 months before the fiscal year for which prospective payment rates are to be re-based; (5) "budget" and "budgeting" mean the financial data for, and the process of, developing a capital budget for annual submission to the department, by a facility that has received a certificate of need for the facility’s prospective fiscal year or for a facility that has a rate established under 7 AAC 150.160(g)(3)(B); (6) "capital" means capital-related costs as determined in accordance with 42 C.F.R. 413.130 - 413.153, governing the Medicare cost report; (7) "certificate" or "certificate of need" means a certificate of need required by and approved under AS 18.07 and 7 AAC 07; (8) "charges" means amounts that patients are billed for health care services provided by a facility; (9) "charity care" means health care services that

(A) a facility does not expect to result in cash payments; and (B) result from a facility’s policy to provide health care services free of charge to an individual who meets certain financial criteria;

(10) "clinical laboratory service" means a biological, microbiological, serological, chemical, immunohematological, hematological, biophysical, cytological, pathological, or other examination of materials derived from the human body, for the purpose of diagnosis, prevention, or treatment of a disease, or assessment of a medical condition of a human being; (11) "CMC DSH" means a children’s medical care DSH; (12) "commissioner" means the commissioner of the health and social services or the commissioner’s designee;


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(13) "cost center" means a breakout of costs on the Medicare cost report related to a particular type of service or administrative function at the facility; (14) "department" means the Department of Health and Social Services; (15) "depreciation" means the systematic distribution of the cost or other base of a tangible asset over the estimated useful life of the asset; (16) "deputy commissioner" means a deputy commissioner of the department or the deputy commissioner’s designee; (17) "DET DSH" means a designated evaluation and treatment DSH; (18) "DSH" means disproportionate share hospital; (19) "effective date" means the date on which a new or modified prospective payment rate is determined by the department to be effective; (20) "findings and recommendations" means the analysis of a facility prospective payment rate or amendment to the prospective payment rate, the resulting findings, and the department’s recommendations relating to the acceptance or modification of a facility’s proposed prospective payment rates or effective dates; (21) "fiscal year" means the operating or business year of a facility; "fiscal year" includes 12 consecutive calendar months; (22) "generally accepted accounting principles" means accounting principles approved by the Financial Accounting Standards Board (FASB); (23) "government entity" means an entity that qualifies as a unit of government for the purposes of 42 U.S.C. 1396b(w)(6)(A); (24) "IMD DSH" means an institution for mental disease DSH; (25) "institution for mental disease" or "IMD" means a facility of more than 16 beds that is primarily engaged in providing diagnosis, treatment, or care of individuals with mental diseases, including medical attention, nursing care, and related services; whether an institution is an institution for mental disease is determined by its overall character as that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases, whether or not the facility is licensed as such;; (26) "intergovernmental transfer" means a transfer of money between state or local governments and public facilities; (27) "licensed capacity days" means the number of beds for which the facility is licensed under 7 AAC 12.900 in the base year, multiplied by 365; (28) "LI DSH" means a low-income DSH; (29) "LUR" means the amount over a low-income utilization rate exceeding 25 percent as calculated in 7 AAC 150.180(d)(2); (30) "Medicaid nursing facility day" means a nursing facility day that is a Medicaid covered day of service; (31) "Medicaid patient day" means a patient day that is a Medicaid covered day of service; (32) "Medicaid utilization rates" means, in acute care, the percentage of Medicaid acute care patient days within a hospital’s total acute care patient days for a fiscal year; (33) "MHCA DSH" means a mental health clinic assistance DSH; (34) "MIU DSH" means a Medicaid inpatient utilization DSH; (35) "MR-0-14 report" means the cost settlement detail report, generated


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by the department, of the claims processed and paid for by Medicaid for each facility; (36) "new facility" means a facility that has not, during the previous 36 months, provided the same or similar level of Medicaid certified patient services within 25 miles of the facility either through present or previous ownership; (37) "notify" means to place written notice of an action in the United States mail or other independent national post carrier, addressed to the last known address of a person, or to deliver written notice by hand to a person; (38) "nursery day" means a calendar day related to inpatient nursing care of a newborn infant in a hospital nursery; (39) "nursing facility day" means a calendar day of care in a nursing facility, including the day of admission and not the day of discharge; (40) "patient day" means a calendar day of inpatient care, including the day of admission and not the day of discharge; (41) "prospective payment rate" means the rate described in 7 AAC 150.040 and authorized by the department to be paid to a facility for services provided to Medicaid recipient; (42) "psychiatric hospital" means a facility that primarily provides inpatient psychiatric services for the diagnosis and treatment of mental illness; "psychiatric hospital" does not include a residential psychiatric treatment center; (43) "public facility" means a hospital that is, or is owned by, a government entity; (44) "re-basing" means a change in the base year as described in 7 AAC 150.160(a)(3); (45) "RHCA DSH" means a rural hospital clinic assistance DSH; (46) "ROGA DSH" means a remainder of government allocation DSH; (47) "SATP DSH" means a substance abuse treatment provider DSH; (48) "SDM" means the amount over a Medicaid inpatient utilization rate at least one standard deviation above the mean of state Medicaid inpatient utilization rates for all hospitals in this state as calculated under 7 AAC 150.180(d)(1); (49) "specialty hospital" means a rehabilitation hospital that is operated primarily for the purpose of inpatient care assisting in the restoration of persons with physical disabilities; (50) "SPEP DSH" means a single point of entry psychiatric DSH; (51) "state" means the State of Alaska; (52) "swing-bed day" means a calendar day related to a hospitalization for treatment of a patient whose hospital level of care is reduced to nursing facility level without a physical move of the patient; (53) "swing-bed rate" means a rate set under 7 AAC 150.160(i); (54) "terms of issuance" means the terms specified by a certificate of need describing the nature and extent of the activities authorized by the certificate; (55) "uninsured care" means services provided to patients without health insurance or another source of third-party payments that applied to services rendered during the qualifying year; (56) "year-end report" means the report submitted to the department that contains the following:

(A) the uniform Medicare cost report as submitted to the Medicare


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intermediary; (B) the Medicare home office cost statements and any audit performed by Medicare of those statements, if applicable; (C) the Medicare provider cost report payment questionnaire; (D) any supporting schedules sent to the Medicare intermediary with the Medicare cost report; (E) audited financial statements specific to the reporting facility and matching the time period of the Medicare cost report that identify the facility’s financial information; (F) audit adjustments made by the financial statement auditors; (G) reconciliation of the audited financial statements to the Medicare cost report worksheet A; (H) post-audit working trial balance; (I) reconciliation of the post-audit working trial balance to the Medicare cost report worksheets A, A-8, C, and G series; (J) appropriate Medicaid reporting forms from the Medicaid Hospital and Long-Term Facility Reporting Manual, adopted by reference in 7 AAC 160.900. (Eff. 2/1/2010, Register 193)



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Department Note Regarding Tribal Health Programs: Look for future development of Chapter 155, Tribal Health Programs. The Department of Health and Social Services intends to develop comprehensive regulations addressing tribal health program coverage and payment. When developed they will be published as proposed regulations, subject to public hearings, and subsequent legal review. When those regulations are filed and effective, they will be located in 7 AAC 155 below.

Chapter 155. Tribal Health Programs. Section 10. Tribal health program payment methodology 20. Community health aides and practitioners 7 AAC 155.010. Tribal health program payment methodology. Notwithstanding any other payment provisions of 7 AAC 43 and 7 AAC 105 - 7 AAC 160, the department will pay a tribal health program using (1) the Indian Health Service encounter rates, adopted by reference in 7 AAC 160.900; or (2) the payment methodology applicable to a nontribal provider in 7 AAC 145, if the tribal health program has elected, under 25 U.S.C 1645, to use that payment methodology for a selected range of services covered under 7 AAC 43 and 7 AAC 105 - 7 AAC 160. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 155.020. Community health aides and practitioners. For the services of a community health aide III or IV or a community health practitioner certified by the Community Health Aide Program Certification Board, the department will pay, (1) under 7 AAC 145.020, a physician enrolled under 7 AAC 43 and 7 AAC 105 - 7 AAC 160; or (2) under 7 AAC 155.010, a tribal health program enrolled under 7 AAC 43 and 7 AAC 105 - 7 AAC 160. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040


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Chapter 160. Medicaid Program; General Provisions. Article 1. Program Integrity and Quality Assurance (7 AAC 160.100 - 7 AAC 160.140) 2. Third-Party Liability; Estate Recovery (7 AAC 160.200 - 7 AAC 160.250) 3. General Provisions (7 AAC 160.900 - 7 AAC 160.990)

Article 1. Program Integrity and Quality Assurance. Section 100. Program integrity 110. Fiscal audit 120. Use of statistical sampling 130. Appeal 140. Quality assurance program 7 AAC 160.100. Program integrity. The department or its designee shall provide for and operate program integrity activities designed to promote the economical and effective administration of the department’s Medicaid program. These activities may include the following: (1) operation of a surveillance, utilization, and review subsystem within the department’s system to manage Medicaid information; (2) audit activities designed to investigate fraud, abuse, over-utilization or Medicaid program compliance by providers; (3) utilization review under 7 AAC 160.140; (4) coordination with the Department of Law, the United States Department of Justice, and the United States Office of Inspector General. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.074 AS 47.05.200 AS 47.07.040 7 AAC 160.110. Fiscal audit. (a) The department or its designee shall conduct fiscal audits of Medicaid providers. (b) For purposes of this section, a fiscal audit may include a desk audit, a field audit, or both, to determine the provider’s compliance with the requirements of 42 U.S.C. 1396, AS 47.05, AS 47.07, 42 C.F.R. Part 430 - 42 C.F.R. Part 498, 7 AAC 43, 7 AAC 105 - 7 AAC 160, and the provider’s current provider agreement made under 7 AAC 105.220. (c) For purposes of conducting an audit under this section, the provider must allow the department or its designee, the federal government, or the Department of Law access to original financial, clinical, and other records documenting care provided to Medicaid recipients. (d) Except as provided in (e) of this section, the department or its designee will give a provider 30 days' advance notice of an audit to be conducted under this section. The notice will (1) advise the provider that the department or its designee intends to conduct an audit of the provider’s records; (2) specify the place where the audit is to be conducted;


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(3) specify the records that the provider must produce for purposes of the audit; (4) specify the date by which the provider must produce the records and the address to which the records are to be delivered or inspected; and (5) advise the provider that the provisions of 7 AAC 105.240 apply to the production of the records requested. (e) The department or its designee may request records and perform an audit of those records without advance notice if the department or its designee has reason to believe, based on reliable evidence, that the provider is engaging in a course of conduct or performing an act in violation of the requirements specified in (b) of this section. Notwithstanding the provisions of 7 AAC 105.240, the provider shall produce the requested records for an immediate audit under this subsection at the provider’s place of business or other location as specified by the department or its designee. (f) Following the department’s or its designee’s audit of a provider’s records, the department or its designee will give the provider the written preliminary findings of the audit. The preliminary findings will identify claim-line inaccuracies, but will not identify any overpayment amounts. The provider has 30 days after the date of the letter informing the provider of the preliminary findings to submit additional documentation or respond to the preliminary findings. (g) The department will issue the final audit report to the provider no more than 60 days after it has considered any documentation or response submitted under (f) of this section and the audit is complete. The final audit report will include audit or review findings and overpayment amounts identified as a result of the audit. (h) If the department finds in the final audit report under (g) of this section that the provider has not complied with the requirements specified in (b) of this section, the department will take one or more of the following actions: (1) recoup any identified overpayment amount from the provider; (2) impose sanctions against the provider under 7 AAC 105.400 - 7 AAC 105.490; (3) initiate other administrative or other civil actions; (4) refer the matter to another state, federal, or local agency. (i) For purposes of this section, (1) "audit" means the process of obtaining competent evidentiary material about a provider through inspection, observation, inquiry, and confirmation sufficient to support a reasonable basis for determining the provider’s compliance with the legal requirements of the Medicaid program; (2) "desk audit" means an audit of a provider conducted by the department or its designee based upon an examination of a provider’s records without a visit to the provider’s place of business or site where the provider maintains business records; (3) "field audit" means an audit of a provider conducted by the department or its designee based upon an examination of a provider’s records with at least one on-site visit to conduct audit procedures at the provider’s place of business or site where the provider maintains business records. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.074 AS 47.05.200 AS 47.07.040


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7 AAC 160.120. Use of statistical sampling. The department or its designee may use statistically valid sampling methodologies to (1) select Medicaid claims for review or audit; and (2) calculate overpayment amounts to providers that are subject to a fiscal audit under 7 AAC 160.110 or a quality assurance program review under 7 AAC 160.140. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 160.130. Appeal. (a) A provider may appeal the findings of a final audit conducted under 7 AAC 160.110 and determinations of overpayment amount under the audit. (b) An appeal under this section must (1) be made in writing and submitted to the Commissioner’s Office, Department of Health and Social Services, P.O. Box 110601, Juneau, Alaska 99811-0601; (2) be submitted to the commissioner no more than 30 days after the date of the letter transmitting the provider’s final audit report; (3) contain a description of the finding or determination being appealed, a copy of the determination, and the basis upon which the final audit report is challenged; and (4) include all information and materials, including any new information that the provider requests the commissioner to consider in resolving the appeal. (c) The commissioner will review the information and materials submitted under (b) of this section and consider the following factors in reaching a decision on an appeal under this section: (1) the provider’s error rate in the audit; (2) whether the provider has a prior history of similar audit findings and whether the previous findings were corrected; (3) whether the provider received notice of noncompliance previously and whether the provider received training regarding the noncompliance; (4) whether the provider submitted false or fraudulent information, or omitted material information, on the Medicaid claims to the department; (5) whether the findings of the audit indicate that the provider poses a health or safety risk to recipients. (d) The commissioner’s decision under this section is a final administrative decision. The department will notify the provider of the provider’s right to appeal the final administrative decision to the superior court under the Alaska Rules of Appellate Procedure. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.05.200 AS 47.07.040 7 AAC 160.140. Quality assurance program. (a) The department will establish a quality assurance program to ensure provider compliance with AS 47.05, AS 47.07, and 7 AAC 105 - 7 AAC 160. (b) Under the quality assurance program, the department will conduct random program reviews of a sampling of providers on an annual basis. After each review, the


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department will issue a written report of findings as to whether the provider was in compliance with the provisions of AS 47.05, AS 47.07, 7 AAC 43, and 7 AAC 105 - 7 AAC 160. (c) If the department finds in the written report under (b) of this section that the provider has not complied with AS 47.05, AS 47.07, 7 AAC 43, or 7 AAC 105 - 7 AAC 160, the department may take one or more of the following actions: (1) give the provider notice under 7 AAC 105.440 that the department proposes to immediately suspend a provider’s participation in the Medicaid program; (2) find grounds under 7 AAC 105.400 to sanction the provider under 7 AAC 105.410; (3) require that the provider be audited if there is a reasonable basis to conclude that the provider has received payments in excess of what is authorized under the Medicaid program; (4) require the provider to issue a corrective action plan to address the written report of findings issued under (b) of this section; (5) initiate other administrative or other civil actions; (6) refer the matter to

(A) another state, federal, or local agency; (B) the Division of Corporations, Business and Professional Licensing in the Department of Commerce, Community, and Economic Development; and (C) applicable certifying and accrediting agencies.

(d) As a condition for participation in the Medicaid program, an ambulatory surgical center or a hospital, including an inpatient hospital, must have in effect a utilization review plan approved by the United States Department of Health and Human Services if utilization review is performed by a federally contracted Quality Improvement Organization (QIO). The written plan submitted by the hospital or the QIO on behalf of the hospital must include the detailed provisions described in 42 C.F.R. 456.50 - 456.145, adopted by reference in 7 AAC 160.900. (e) The approved utilization review plan described in (d) of this section must be implemented through the QIO or a hospital that has been delegated review authority by the QIO. (f) As a condition for participation in the Medicaid program, a hospital must participate in a review of health care services to Medicaid recipients. The department or its designee will conduct an annual on-site hospital review under this subsection. The review will be planned in advance and in coordination with the hospital. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040


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Article 2. Third-Party Liability; Estate Recovery. Section 200. Third-party resources 210. Estate Recovery 220. Liens 230. Appealing a lien 240. Waiving estate recovery 250. Exemptions from estate recovery 7 AAC 160.200. Third-party resources. (a) The department will pay for a service, prescription drug, or supply only to the extent it is a covered service under AS 47.07.030 and 7 AAC 105 - 7 AAC 160 and only after the recipient has made full use of any other third-party resources available to pay for that service, prescription drug, or supply. A third-party resource includes (1) workers' compensation under a law or plan of the United States or a particular jurisdiction; (2) private, employer-based, or public health insurance; (3) a prepaid health plan; (4) a program or health plan of the federal government, including

(A) Veterans Administration benefits, (B) the TRICARE military health plan under 10 U.S.C. 1071 - 1110 for active duty military personnel, reservists, dependents, and retirees, or other military health plan; and (C) Medicare;

(5) the fishermen’s fund (AS 23.35.060); (6) automobile insurance, including uninsured or underinsured motorist insurance; (7) an indemnity policy; and (8) another jurisdiction's Medicaid or other medical assistance program. (b) If a provider treats a recipient for an injury that the provider has reason to believe may have been caused by another individual, institution, corporation, business, or public or private agency, the provider shall notify the department of that belief at the time of billing. The department will evaluate this information to determine if there is potential for legal action, recovery from a settlement, or payment from a third-party resource. The department will not delay payment to the provider pending an evaluation. (c) If a third-party resource makes a demand for the refund of a claim previously paid by the third-party resource and the billing deadline in 7 AAC 145.005(c) has expired, the provider has 60 days after the date of demand to bill Medicaid or adjust the original claim. The provider shall include a copy of the third-party resource’s demand letter and proof of the refund that the provider made to the third-party resource with the claim. (d) For purposes of this section, a tribal health program is not a third-party resource. (e) In this section, "has made full use of" means the recipient has applied for, reasonably cooperated with, and to the extent possible has maintained eligibility for, a third party that will pay for a service, prescription drug, or supply otherwise covered


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under AS 47.07.030 and 7 AAC 105 - 7 AAC 160. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 160.210. Estate recovery. (a) At the time of application, the department will notify each applicant for medical assistance that the estate of an individual who received medical assistance benefits may be subject to a claim for recovery under AS 47.07.055 and 7 AAC 160.210 - 7 AAC 160.250. (b) When the state determines under 7 AAC 160.220 that a recipient who is subject to estate recovery under AS 47.07.055 cannot be expected to return home or has died, the department will determine (1) the estimated value of the estate; (2) if there is a surviving spouse or other estate beneficiaries; and (3) if proceeding with recovery in accordance with (c) of this section will be permissible and cost effective. (c) The department will pursue a claim only if it determines that the potential recovery amount would result in twice the administrative and legal cost of pursuing the claim, with a minimum pursuable net amount of $10,000. In assessing the value of an estate, the department will consider allowances and all other claims against the estate having precedence under state statute. For the purposes of this subsection "administrative and legal costs" include the costs of (1) advertising, filing, and exercising a lien; (2) legal representation of the state; (3) tracking property with potential for a lien and then tracking its subsequent recovery; (4) repair of the property to bring it into saleable condition; (5) insurance to protect the asset; and (6) advertising, listing, and selling the home including all applicable closing fees. (d) When making a claim for reimbursement under AS 47.07.055(e), the department will include in that claim any hospital and prescription drug services provided to a recipient while the recipient was receiving services identified in AS 47.07.055(e)(1) or (2). (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.055

7 AAC 160.220. Liens. (a) For purposes of AS 47.07.055(a)(3), if a recipient resides in a medical institution for at least 120 consecutive days, the department will give the recipient (1) notice of its intent to determine that the recipient is not reasonably expected to be discharged from the institution and return home; and (2) an opportunity for a hearing regarding that determination. (b) A transfer from one medical institution to another does not interrupt the 120-day period for the purposes of (a) of this section. A discharge from a medical institution to a community setting terminates the 120-day period. Re-admission to a medical institution starts a new 120-day period. (c) The department will not pursue recovery under a lien filed under


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AS 47.07.055(a) against a recipient's home while the recipient's child 21 years of age or older is lawfully residing in the home and can provide documentation that (1) the child resided with the recipient in the recipient’s home for at least 24 months immediately preceding the recipient’s admission into a medical institution; (2) the child has continued to reside in the recipient’s home continuously since the institutionalization began; and (3) the care the child provided enabled the recipient to stay at home rather than move to a medical institution. (d) Documentation under (c) of this section must include (1) written evidence that the child used the recipient’s address as the child’s mailing address on the child’s driver’s license or voter registration, and that the child’s address remained unchanged throughout this entire time period; and (2) a written statement from the recipient residing in a medical institution or the recipient’s treating physician that the child’s presence in the home had enabled the recipient to live in the community longer, postponing the need to move to the medical institution. (e) If the department has decided to place a lien on real property of a recipient, the department shall notify the recipient of the department’s intent to place a lien on the real property and to proceed with recovery on the lien after the death of the recipient's surviving spouse, if any. In the notice, the department will include (1) the recipient’s name, date of birth, and date of death, if deceased; (2) the definition of the term "lien"; (3) an explanation that estate beneficiaries will not lose ownership of the real property if the lien is imposed; (4) the amount of recoverable Medicaid benefits correctly paid on behalf of the recipient; (5) the department’s intent to file a lien against the recipient’s real property to recover the applicable Medicaid benefits paid on behalf of the recipient; and (6) how to request a hardship waiver and how to appeal the department’s decision to proceed with recovery. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.055 7 AAC 160.230. Appealing a lien. (a) After receiving a notice under 7 AAC 160.220(e) from the department, the recipient, legal representative of the recipient, or estate beneficiary may file an appeal with the department to (1) contest the amount of recoverable medical assistance identified by the department; (2) contest whether the real property is a part of the recipient’s estate; or (3) request a waiver of recovery for undue hardship. (b) An appeal is timely if the department receives it no more than 30 days after the date on the notice. The department will accept an appeal received more than 30 days after, and no more than 60 days after the date on the notice if the individual demonstrates good cause for the late application.

(c) An appeal must (1) be submitted in writing; (2) be signed by the recipient, legal representative of the recipient, or


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estate beneficiary; (3) be submitted in person or by mail to the division of the department that administers the estate recovery provisions of the Medicaid program; (4) include a statement of the reason for contesting the department’s action or explaining the reason why recovery will cause undue hardship; and (5) include contact information for the person contesting the action. (d) The department will make a decision on a request for waiver for undue hardship no more than 30 days after receipt of the request. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.055 Editor’s note: Appeals under 7 AAC 160.230 may be submitted to the Department of Health and Social Services, Division of Health Care Services, Accounting and Recovery Section, 4501 Business Park Blvd., Suite 24, Anchorage, Alaska 99503. 7 AAC 160.240. Waiving estate recovery. (a) After considering the information gathered in accordance with 7 AAC 160.210, or after considering an appeal based on 7 AAC 160.230, the department may waive all or part of the department’s claim for recovery. (b) The department will waive recovery for undue hardship if the department determines that recovery would impoverish the estate beneficiary. To determine if estate recovery would impoverish the estate beneficiary, the department will consider whether (1) the estate’s only asset produces income, and recovery would cause an estate beneficiary’s loss of livelihood; (2) recovery would deprive the beneficiary of food, clothing, shelter, other necessities of life, or medical care, thereby endangering the beneficiary’s health and safety; (3) an estate beneficiary’s primary residence is the estate’s only significant asset and recovery would cause impoverishment of the estate beneficiary as follows:

(A) recovery of the asset would make the beneficiary eligible for public assistance; (B) a beneficiary could discontinue eligibility for public assistance if the beneficiary was to receive the asset; or

(4) a beneficiary’s primary residence is a home of modest value as determined on the date of the recipient’s death; in this paragraph, "modest value" means 50 percent or less of the average price of homes in the community, based on Department of Labor and Workforce Development statistics, and as determined as of the date of the recipient’s death. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.055 7 AAC 160.250. Exemptions from estate recovery. (a) A special low-income Medicare beneficiary under 7 AAC 100.754 who receives assistance from the department only in the form of payment for the beneficiary’s Medicare co-payments or deductibles is exempt from estate recovery. (b) A Medicaid expenditure made for services that a recipient would not have been required to pay for if the recipient was not eligible for Medicaid is exempt from estate recovery.


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(c) American Indian and Alaska Native income and resources, including rents, leases, royalties, usage rights, or income from them, are exempt from estate recovery if that income is or those resources are (1) located on, near, or within the most recent boundaries of a current or prior federally recognized or designated reservation; (2) derived from the passing of land described in (1) of this subsection from an American Indian or an Alaska Native or descendant of an American Indian or Alaska Native to

(A) one or more relatives, by blood, adoption, or marriage; (B) another American Indian or Alaska Native; or (C) an American Indian or Alaska Native group;

(3) derived from the exercise of a federally protected right to extract or harvest natural resources from land described in (1) of this subsection; (4) held in trust or restricted status or are judgment funds that are exempt from recovery by state law, including the following distributions or conveyances by an Alaska Native corporation organized under to 43 U.S.C. 1601 - 1629h (Alaska Native Claims Settlement Act (ANCSA)) to an Alaska Native or descendant of an Alaska Native:

(A) stock, including stock issued or distributed as a dividend or distribution on stock, or bonds issued by that corporation; (B) land or an interest land, including land or an interest in land received as a dividend or distribution on stock; (C) a shareholder homesite conveyed under 43 U.S.C. 1620(j); (D) an interest in a settlement trust; and (E) any other property interest that is conveyed, or deemed to be conveyed, under 43 U.S.C. 1601 - 1629h;

(5) originally protected assets and ownership interests that have been inherited, if the protected source can be clearly traced; or (6) ownership interest in or usage rights to items not included in this subsection, with unique religious, spiritual, traditional, or cultural significance or usage rights that support subsistence or a traditional lifestyle in accordance with applicable tribal law or custom. (d) In this section, (1) "Alaska Native group" has the meaning given "Native group" in 43 U.S.C. 1602(d); (2) "settlement trust" means a trust

(A) established and registered (i) by an Alaska Native corporation organized under 43 U.S.C. 1601 - 1629h; and (ii) under the laws of the state and under a resolution of its shareholders; and

(B) operated for the benefit of shareholders, Alaska Natives, and descendants of Alaska Natives, in accordance with 43 U.S.C. 1629e (sec. 39 of the Alaska Native Claims Settlement Act) and the laws of the state. (Eff. 2/1/2010, Register 193)



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Article 3. General Provisions. Section 900. Requirements adoption by reference 990. Definitions 7 AAC 160.900. Requirements adopted by reference. (a) The following documents referenced in 7 AAC 105 - 7 AAC 160 are adopted by reference: (1) American Medical Association, Current Procedural Terminology, Professional Edition, as revised for 2010 ("CPT 2010"), as amended from time to time; (2) United States Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS), Healthcare Common Procedure Coding System (HCPCS) 2010, as amended from time to time, and published by the American Medical Association; (3) International Classification of Diseases - 9th Revision, Clinical Modification (ICD-9-CM), 2010 revision, as amended from time to time, and published by the American Medical Association; (4) American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000 (DSM-IV-TR), as amended from time to time; (5) United States Department of Health and Human Services, National Institutes of Health, Glossary of Terms for Human Subjects Protection and Inclusion Issues, dated April 25, 2001; (6) Indian Health Service encounter rates, published in 74 Fed. Reg. 27554 - 27555 (June 10, 2009), as amended from time to time; (7) American Society of Anesthesiologists, Relative Value Guide, 2006, as amended from time to time; (8) the nonfacility individual relative value units (RVUs) for the Medicare program for each medical procedure, including the geographic practice cost indices (GPCI) for this state, as published in 74 Fed. Reg. 62014 - 62146 and 62148 (Addenda A, B, C, and E) (November 25, 2009), as amended from time to time; (9) Drug Facts and Comparisons, 2007 edition, published by Wolters Kluwer Health, Inc.; (10) Overview of the Chart of Accounts, pages 55 - 64 of the publication entitled Chart of Accounts for Hospitals, by L. Vann Seawell, 1994 Edition, ISBN 1-55738-619-6; (11) Alternative Link, ABC Coding Manual for Integrative Healthcare, 9th edition, 2007 first release; (12) Inventory for Client and Agency Planning (ICAP), as revised as of 1986; (13) United States Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS), DMEPOS Fee Schedule 2006 1st Quarter; (14) United States Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS), Ambulatory Surgical Centers (ACS) Approved HCPCS Codes and Payment Rates spreadsheet, revised as of February 26, 2007; (15) United States Department of Health and Human Services, Public


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Health Service, Quick Reference Guide for Clinicians: Treating Tobacco Use and Dependence, dated October 2000, pages 9 - 11; (16) the optional standard mileage rate for medical purposes published in the United States Internal Revenue Service announcement IR-2008-82, published June 23, 2008; (17) Child and Adolescent Functional Assessment Scale, by Kay Hodges, Ph.D., version 7.0, dated 2000; (18) the University of Washington Wraparound Evaluation and Research Team, Wraparound Fidelity Index 4 (WFI-4), revised as of August 13, 2007; (19) the federal Medicare ambulatory surgical center payment rates for federal fiscal year 2000, as set out in 65 Fed. Reg. 6380 - 6383 (February 9, 2000); (20) United States Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS), Medicare National Coverage Determinations Manual, Chapter 1, Part 1, Section 20.10 (Cardiac Rehabilitation Programs), Revision 98, revised as of December 24, 2008; (21) Comptroller General of the United States, Government Auditing Standards, July 2007 revision. (b) The following provisions of federal statutes and regulations are adopted by reference: (1) 42 U.S.C. 1396a(bb)(1) - (6), revised as of December 29, 2007; (2) 42 U.S.C. 1396r-8(k)(6) (definition of "medically accepted indication"), revised as of October 1, 2008; (3) 42 C.F.R. 405.515 (reimbursement for clinical laboratory services billed by physicians), revised as of October 1, 2008; (4) 42 C.F.R. 405.2400 - 405.2472 (rural health clinic and federally qualified health clinic services), revised as of October 1, 2008; (5) 42 C.F.R. Part 418 (hospice care), revised as of October 1, 2008; (6) 42 C.F.R. Part 442 (standards for payment to nursing facilities and intermediate care facilities for the mentally retarded), revised as of October 1, 2008; (7) 42 C.F.R. 447.280 (hospital providers of NF services (swing-bed hospitals)), revised as of October 1, 2008; (8) 42 C.F.R. 447.300 - 447.371 (payment methods for other institutional and noninstitutional services), revised as of October 1, 2008; (9) 42 C.F.R. 447.512 (drugs: aggregate upper limits of payment), revised as of October 1, 2008; (10) 42 C.F.R. 447.514 (upper limits for multiple source drugs), revised as of October 1, 2008; (11) 42 C.F.R. Part 456 (utilization control), revised as of October 1, 2008; (12) 42 C.F.R. Part 483 (requirements for states and long term care facilities), revised as of October 1, 2008; (13) 42 C.F.R. 485.701 - 485.729 (conditions of participation for clinics, rehabilitation agencies, and public health agencies as providers of outpatient physical therapy and speech-language pathology services), revised as of October 1, 2008; (14) 42 C.F.R. 486.100 - 486.110 (conditions for coverage: portable x-ray services), revised as of October 1, 2008;


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(15) 42 C.F.R. 488.11 (state survey agency functions) and 42 C.F.R. 488.26 (determining compliance), revised as of October 1, 2008; (16) 42 C.F.R. Part 491 (certification of certain health care facilities), revised as of October 1, 2008. (c) The provisions of 12 AAC 44.965, revised as of November 4, 2004, are adopted by reference. (d) The following department documents are adopted by reference: (1) the Alaska Medicaid Preferred Drug List, Version 111809, revised as of November 18, 2009; (2) the Alaska Medicaid Prior-authorized Medications list, dated September 30, 2009; (3) the description of diagnoses and procedures included in the Select Diagnoses and Procedures Pre-certification List, revised as of January 2008; (4) the Durable Medical Equipment Prior Authorization List, dated August 2005; (5) the Table of ICAP Broad Independence Scores by Age, revised as of April 5, 2004; (6) the Consumer Assessment Tool (CAT), revised as of January 29, 2009; (7) the PCAT Authorized Services Plan, revised as of January 29, 2009; (8) the Home and Community-Based Waiver Services Certification Application Packet, revised as of April 21, 2006; (9) the Personal Care Assistant Agency Certification Application Packet, dated 2005; (10) the Current Waiver Services Regulatory Rates table, revised as of July 1, 2008; (11) Alaska Commission on Aging, Alaska State Plan for Senior Services, New Funding Formula for Title III and Title V Programs table, page 106, revised for FY 2010 - 2011; (12) the Alaska Immunization Recommendations, published January 10, 2006; (13) the Alaska Periodicity Schedule for Child and Adolescent Health Screening, including reference notes, adopted February 29, 2000; (14) the Addresses for Second Level Provider Appeals list, revised August 2006; (15) the revenue codes listed in Section I, pages I-1 - I-10 of the Inpatient/Outpatient Hospital Services section of the Alaska Provider Billing Manual, revised as of March 2006; (16) the Covered Revenue Codes for Outpatient Hospitals table, pages D-11 - D-24 and the Covered Revenue Codes for Inpatient Hospitals table, pages E-12 - E-26, of the Indian Health Service (IHS)/Tribal Facility Services section of the Alaska Provider Billing Manual, revised as of April 15, 2005; (17) Table I-1, Procedure Codes: Mental Health Services of the Federally Qualified Health Center / Rural Health Clinic Services section of the Alaska Provider Billing Manual, revised as of January 2003; (18) the Specialized Medical Equipment Fee Schedule 2006 for home and community-based waiver services;


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(19) the State of Alaska, Department of Health and Social Services, Behavioral Health Inpatient Psychiatric Review Provider Manual, revised as of April 2008. (20) Medicaid Hospital and Long-Term Care Facility Reporting Manual, dated September 2005; (21) Medicaid Log of Uninsured Care Reporting Form, dated February 26, 2002. (e) The following department fee schedules are adopted by reference: (1) 2009 CPT Fee Schedule for Chiropractic Services, Table I-3, revised as of March 20, 2009; (2) 2009 CDT Procedure Codes: Dental Services for Children, Table I-3; CDT Procedure Codes: Emergent Dental Services for Adults, Table I-4a, and 2009 CDT Procedure Codes: Enhanced Dental Services for Adults, Table I-4b, revised as of June 24, 2009; (3) 2009 CPT Fee Schedule for Direct Entry Midwife Services, Table I-3.(a), revised as of June 17, 2009, and 2009 HCPC Fee Schedule for Direct Entry Midwife Services, Table I-3.(b), revised as of March 20, 2009; (4) 2009 HCPC Fee Schedule for Audiology Services, Table I-2(b), and 2009 HCPC Fee Schedule for Hearing Aid Dealer Services, Table I-3, revised as of March 20, 2009; (5) 2009 CPT Fee Schedule for Home Infusion Therapy Services, Table I-3(a), revised as of February 23, 2009, and 2009 HCPC Fee Schedule for Home Infusion Therapy Services, Table I-3(b), revised as of July 27, 2009; (6) 2009 HCPC Fee Schedule for Incontinence Supplies, Table I-1, revised as of February 23, 2009; (7) 2009 CPT Fee Schedule for Occupational Therapy Services, Table I-6.(a), and 2009 HCPC Fee Schedule for Occupational Therapy Services, Table I-6.(b), revised as of March 19, 2009; (8) 2009 CPT Fee Schedule for Outpatient Therapy Services, Table I-3.(a), and 2009 HCPC Fee Schedule for Outpatient Therapy Services, Table I-3.(b), revised as of March 19, 2009; (9) 2009 CPT Fee Schedule for Independent Physical Therapists, Table I-4.(a), and 2009 HCPC Fee Schedule for Independent Physical Therapists, Table I-4.(b), revised as of March 19, 2009; (10) 2009 CPT Fee Schedule for Podiatry Services, Tables I-3.(a), and 2009 HCPC Fee Schedule for Podiatry Services, Table I-3.(b), revised as of March 19, 2009; (11) 2009 CPT Fee Schedule for School-Based Services, Table I-2.(a), and 2009 HCPC and ABC Fee Schedule for School-Based Services, Table I-2.(b), revised as of June 24, 2009; (12) 2009 CPT Fee Schedule for Speech Pathologists, Table I-5.(a), and 2009 HCPC Fee Schedule for Speech Pathologists, Table I-5.(b), revised as of March 19, 2009; (13) Transportation/Accommodation Fee Schedule, Table I-3, revised as of May 2008; (14) 2009 CPT Fee Schedule for Vision Services, Table I-4.(a), revised as


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of April 29, 2009. (f) The United States Department of Health and Human Services federal poverty guidelines for this state, established in 74 Fed. Reg. 4199 - 4201, revised as of January 23, 2009, and as amended from time to time, are adopted by reference. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 AS 47.05.012 Editor’s Note: The American Medical Association’s Current Procedural Terminology (CPT), Professional Edition; the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services’s (CMS) Healthcare Common Procedure Coding System (HCPCS), the International Classification of Diseases - 9th Revision, Clinical Modification (ICD-9-CM), and the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM), all adopted by reference in 7 AAC 160.900, may be obtained by contacting the Order Department, American Medical Association, P.O. Box 930876, Atlanta, Georgia 31193-0876, or by visiting the AMA Bookstore at Internet address: https://catalog.ama-assn.org/Catalog/home.jsp. These publications may also be available at other retail book sellers. A copy of each of these publications is available for examination at the Department of Health and Social Services, Division of Health Care Services, 4501 Business Park Boulevard, Suite 24, Anchorage, Alaska 99503-7167 or the Office of the Commissioner, 350 Main Street, Juneau, Alaska 99801. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, adopted by reference in 7 AAC 160.900, may also be obtained from American Psychiatric Publishing, Inc., 1000 Wilson Boulevard, Suite 1825, Arlington, Virginia 22209-3901, telephone (703) 907-7322 or (800) 368-5777; or from the American Psychiatric Association at the following electronic mail address: [email protected]. The United States Department of Health and Human Services, National Institutes of Health’s Glossary of Terms for Human Subjects Protection and Inclusion Issues, adopted by reference in 7 AAC 160.900, may be obtained by contacting the Department of Health and Social Services, Division of Health Care Services, 4501 Business Park Boulevard, Suite 24, Anchorage, Alaska 99503-7167 or at the National Institutes of Health Internet address: http://grants.nih.gov/grants/peer/tree_glossary.pdf The Federal Register may be obtained through the nearest public library. If the Federal Register is not available at your nearest library, the material can be obtained by the library through the interlibrary loan system. It may also be obtained at http://www.gpoaccess.gov. The American Society of Anesthesiologists’ Relative Value Guide, adopted by reference in 7 AAC 160.900, may be obtained by contacting American Society of Anesthesiologists, 520 N. Northwest Highway, Park Ridge, Illinois 60068-2573, Internet address: http://www2.asahq.org/publications/. The nonfacility individual relative value units (RVUs) for the Medicare program, and the geographic practice cost indices (GCPI) for this state, adopted by reference in 7 AAC 160.900, may be reviewed at the Department of Health and Social Services, Division of Health Care Services, 4501 Business Park Boulevard, Suite 24, Anchorage, Alaska 99503-7167. Drug Facts and Comparisons, adopted by reference in 7 AAC 160.900, may be obtained from the publisher, Wolters Kluwer Health, Inc., by telephone at 800-223-0554 or 314-216-2100. The book may also be ordered from the publisher at http://www.drugfacts.com or by writing to the following address: Wolters Kluwer Health, Inc., 111 West Port Plaza Drive, Suite 300, St. Louis, Missouri 63146-3098. A copy of this document is available for examination at the Department of Health and Social Services, Division of Health Care Services, 4501 Business Park Boulevard, Suite 24, Anchorage, Alaska 99503-7167. Alternative Link’s ABC Coding Manual for Integrative Healthcare, adopted by reference in 7 AAC 160.900, may be obtained from Alternative Link, 6121 Indian School Road NE, Suite 131, Albuquerque, New Mexico 87110; telephone: (505) 875-0001, toll free: (877) 621-5465; fax: (505) 875-0002; or the following Internet address: http://www.alternativelink.com/ali/contact_us/. A copy of this document is available for examination at the Department of Health and Social Services, Division of Health Care Services, 4501 Business Park Boulevard, Suite 24, Anchorage, Alaska 99503-7167. The Inventory for Client and Agency Planning, adopted by reference in 7 AAC 160.900, is


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available for inspection at the Department of Health and Social Services, Division of Senior and Disabilities Services, Court Plaza Building, 240 Main Street, Suite 602, Juneau, Alaska. A copy of the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services' (CMS) DMEPOS Fee Schedule, adopted by reference in 7 AAC 160.900, may be obtained from the Department of Health and Social Services, Division of Health Care Services, 4501 Business Park Boulevard, Suite 24, Anchorage, Alaska 99503-7167. The United States Department of Health and Human Services, Centers for Medicare and Medicaid Services' (CMS) Ambulatory Surgical Centers (ACS) Approved HCPCS Codes and Payment Rates spreadsheet, adopted by reference in 7 AAC 160.900, may be obtained by contacting the Superintendent of Documents, United States Government Printing Office, Washington, D.C. 20402. A copy of this spreadsheet is available for examination at the Department of Health and Social Services, Division of Health Care Services, 4501 Business Park Boulevard, Suite 24, Anchorage, AK 99503-7167 or may be found at the following CMS Internet address: http://www.cms.hhs.gov/ASCPayment/01_Overview.asp. The United States Department of Health and Human Services, Public Health Service’s Quick Reference Guide for Clinicians: Treating Tobacco Use and Dependence, adopted by reference in 7 AAC 160.900, may be obtained by contacting any of the following Public Health Service clearinghouse telephone numbers: Agency for Healthcare Research and Quality (AHRQ), (800) 358-9295; Centers for Disease Control and Prevention (CDC), (800) CDC-1311 ((800) 232-1311); National Cancer Institute (NCI), (800) 4-CANCER ((800) 422-6237). The publication may also be obtained at the following Internet address: www.surgeongeneral.gov/tobacco/tobaqrg.pdf. The United States Internal Revenue Service optional standard mileage rate for medical purposes announcement IR-2008-82, published June 23, 2008, and adopted by reference in 7 AAC 160.900, may be obtained from the Internal Revenue Service at the following Internet address: http://www.irs.gov/newsroom. The Child and Adolescent Functional Assessment Scale, adopted by reference in 7 AAC 160.900, may be obtained by writing to Functional Assessment Systems, 3600 Green Court, Suite 110, Ann Arbor, MI 48105, or may be inspected at the Department of Health and Social Services, Division of Behavioral Health, 3601 C Street, Suite 878, Anchorage, Alaska. A copy of the Wraparound Fidelity Index 4 (WFI-4), adopted by reference in 7 AAC 160.900, may be obtained by contacting the Wraparound Evaluation and Research Team, Division of Public Behavior Health and Justice Policy, University of Washington, 2815 Eastlake Avenue East, Suite 200, Seattle, WA 98102; e-mail: [email protected]. The department’s Alaska Medicaid Preferred Drug List, Alaska Medicaid Prior-Authorized Medications List, and Select Diagnoses and Procedures Pre-certification List, adopted by reference in 7 AAC 160.900, may be obtained from the Department of Health and Social Services, Division of Health Care Services, 4501 Business Park Boulevard, Suite 24, Anchorage, AK 99503-7167; or may be obtained at the department’s Internet site at http://www.hss.state.ak.us/dhcs/. The Durable Medical Equipment Prior Authorization List, adopted by reference in 7 AAC 160.900, may be obtained from the Department of Health and Social Services, Division of Health Care Services, 4501 Business Park Boulevard, Suite 24, Anchorage, Alaska 99503-7167. The Table of ICAP Scores by Age, Consumer Assessment Tool (CAT), and PCAT Authorized Services Plan, adopted by reference in 7 AAC 160.900, are available for inspection at the Department of Health and Social Services, Division of Senior and Disabilities Services, Court Plaza Building, 240 Main Street, Suite 602, Juneau, Alaska. The Home and Community-Based Waiver Services Certification Application Packet, adopted by reference in 7 AAC 160.900, may be obtained by writing to the Department of Health and Social Services, Division of Senior and Disabilities Services, P.O. Box 110680, Juneau, Alaska 99811-0680, or may be inspected at the Department of Health and Social Services, Division of Senior and Disabilities Services, Court Plaza Building, 240 Main Street, Suite 602, Juneau, Alaska. The Personal Care Assistant Agency Certification Application Packet, adopted by reference in 7 AAC 160.900, may be obtained from the Department of Health and Social Services, Division of Senior and Disabilities Services, 3601 C Street, Suite 310, Anchorage, Alaska 99503. The Current Waiver Services Regulatory Rates table dated July 1, 2008 and adopted by reference in 7 AAC 160.900, may be obtained by contacting the Department of Health and Social Services, Division of Senior and Disability Services, P.O. Box 110680, Juneau, Alaska, 99811-0680. The Waiver Service


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Regulatory Rates table is also posted on the Department of Health and Social Services, Division of Senior and Disabilities Services' website at http://hss.state.ak.us/dsds/grantservices/hcbproviderresources.htm. The FY 2010 - 2011 New Funding Formula for Title III and Title V Programs table, page 106, of the Alaska Commission on Aging Alaska State Plan for Senior Services, FY 2008 - FY 2011, adopted by reference in 7 AAC 160.900, may be obtained by contacting the Department of Health and Social Services, Division of Senior and Disability Services, P.O. Box 110680, Juneau, Alaska 99811-0680. The Alaska Commission on Aging State Plan for Senior Services is also posted on the Department of Health and Social Services, Alaska Commission on Aging’s Internet site a http://www.alaskaaging.org/documents/statePlanFinalFY08_FY11.pdf. A copy of the Alaska Immunization Recommendations, adopted by reference in 7 AAC 160.900 may be obtained by contacting the Department of Health and Social Services, Division of Public Health, Section of Epidemiology, P.O. Box 240249, Anchorage, Alaska 99524 or visiting its web site at http://www.epi.hss.state.ak.us/id/immune.stm. The Alaska Periodicity Schedule for Child and Adolescent Health Screening, with reference notes, adopted by reference in 7 AAC 160.900, is available for examination at the Department of Health and Social Services, Division of Health Care Services, 4501 Business Park Boulevard, Suite 24, Anchorage, AK 99503-7167. The Addresses for Second Level Provider Appeals list, adopted by reference in 7 AAC 160.900, may be obtained from the Department of Health and Social Services, Division of Health Care Services, 4501 Business Park Boulevard, Suite 24, Anchorage, Alaska 99503-7167. Sections of the Alaska Provider Billing Manual, adopted by reference in 7 AAC 160.900(d), may be obtained at the following Affiliated Computer Services, Inc. Internet site: http://www.medicaidalaska.com/providers/Billing.shtml, or may be obtained by contacting the Department of Health and Social Services, Division of Health Care Services, 4501 Business Park Boulevard, Suite 24, Anchorage, Alaska 99503-7167. The Specialized Medical Equipment Fee Schedule, adopted by reference in 7 AAC 160.900, may be obtained by contacting the Department of Health and Social Services, Division of Senior and Disabilities Services, 3601 C Street, Suite 310, Anchorage, Alaska 99503-5684. The State of Alaska, Department of Health and Social Services, Behavioral Health Inpatient Psychiatric Review Provider Manual, adopted by reference in 7 AAC 160.900, may be obtained by contacting Qualis Health, PO Box 243609, Anchorage, AK 99524-3609, or may be obtained at the following Qualis Health Internet site: http://www.qualishealth.org/cm/alaska-medicaid/behavioral-health/. This manual is also available for inspection at the Department of Health and Social Services, Division of Behavioral Health, 3601 C Street, Suite 878, Anchorage, Alaska 99503. The Medicaid Hospital and Long-Term Care Facility Reporting Manual, and the relevant pages from the Chart of Accounts for Hospitals, adopted by reference in 7 AAC 160.900, are available from the Office of Rate Review, Department of Health and Social Services, 3601 C Street, Ste 978, Anchorage, Alaska 99503. The Medicaid Log of Uninsured Care Reporting Form, adopted by reference in 7 AAC 160.900, is available from the Department of Health and Social Services, DSH Program, P.O. Box 110660, Juneau, Alaska 99811-0660. The department fee schedules, adopted by reference in 7 AAC 160.900(e), may be obtained by contacting the Department of Health and Social Services, Division of Health Care Services, 4501 Business Park Boulevard, Suite 24, Anchorage, Alaska 99503-7167, or may be obtained at the following Affiliated Computer Services, Inc.’s Internet site: http://www.medicaidalaska.com/providers/FeeSchedule.asp 7 AAC 160.990. Definitions. (a) In the definition of "health facility" in AS 47.07.900, "outpatient surgical clinic" means an ambulatory surgical center. (b) In 7 AAC 105 - 7 AAC 160, unless the context requires otherwise, (1) "Alaska Native" has the meaning given "Native" in 43 U.S.C. 1602(b); (2) "ambulatory surgical center" has the meaning given in AS 47.32.900; (3) "American Indian" has the meaning given "Indian" in 25 U.S.C. 479; (4) "claim" means a request for payment submitted to the department, on


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paper or electronically, by a Medicaid provider who has provided a service to a recipient under 7 AAC 105 - 7 AAC 160; (5) "clinical social worker" means an individual licensed as a clinical social worker under AS 08.95; (6) "CMS" means the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services; (7) "community mental health clinic" means a program

(A) headed by a (i) physician, who may be a psychiatrist; or (ii) psychologist or mental health professional clinician working under the general direction of a physician;

(B) that provides mental health services; and (C) operates

(i) under 7 AAC 71; or (ii) as a state-operated community mental health clinic;

(8) "continued stay" mean a stay in a facility that is uninterrupted by a discharge and readmission; (9) "covered" or "coverage" means the department pays for all or part of that service as a Medicaid service under AS 47.07.030 and 7 AAC 105 - 7 AAC 160; (10) "criminal history check" means the processing of an individual’s fingerprints, name, social security number, and other identifying information as described in 7 AAC 10.915; (11) "crisis intervention" means short-term mental health services provided to a recipient during an acute episode of a mental, emotional, or behavioral disorder, that are intended to reduce the symptoms of the disorder, prevent harm to the recipient or others, prevent further relapse or deterioration of the recipient’s condition, or stabilize the recipient; (12) "department" means the Department of Health and Social Services; (13) "dispensing provider" means one of the following entities, if that entity dispenses drugs as part of a medical practice, does not employ a pharmacist to dispense drugs, and is not enrolled with Medicaid as an outpatient pharmacy:

(A) a physician; (B) a podiatrist; (C) a physician assistant; (D) an advanced nurse practitioner; (E) a rural health clinic that meets the requirements of 7 AAC 140.210; (F) a federally qualified health center that meets the requirements of 7 AAC 140.205; (G) a tribal health program;

(14) "EPSDT" means the early periodic screening, diagnosis, and treatment program under Medicaid; (15) "estate" has the meaning given in AS 13.06.050; (16) "facility" means

(A) a general acute care hospital; (B) a specialty hospital; in this subparagraph, "specialty hospital"


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has the meaning given in 7 AAC 150.990; (C) a nursing facility; (D) an intermediate care facility for the mentally retarded; (E) an inpatient psychiatric hospital; (F) a rural health clinic; (G) a federally qualified health center; (H) an ambulatory surgical center; (I) a home health agency, except that in 7 AAC 150, "facility" does not include a home health agency; or (J) a residential psychiatric treatment center, except that in 7 AAC 150, "facility" does not include a residential psychiatric treatment center;

(17) "family psychotherapy" means a form of therapy in which members of a family or any two or more individuals sharing a household, one of whom is a Medicaid recipient, attend psychotherapy sessions together for the treatment of relationships within the family or household to achieve better emotional, behavioral, or social adjustments of all the individuals within the family or household; (18) "federal and state laws" means laws of the United States government and laws of a jurisdiction of the United States; (19) "federally qualified health center" means a facility that has filed an agreement with the department to provide federally qualified health center services under Medicaid; (20) "fiscal agent" means an organization that processes and pays provider claims on behalf of the department; (21) "freestanding facility" means a facility that is individually licensed and enrolled to provide health care services independent from administrative or financial control of another facility; (22) "functional assessment" has the meaning given in 7 AAC 43.1990; (23) "general acute care hospital" has the meaning given in 7 AAC 12.990; (24) "group practice" means a legally organized partnership, professional corporation, foundation, nonprofit corporation, or similar association comprised of one or more health care providers; (25) "group skill development services" means face-to-face therapeutic skill instruction, skill practice, and skill monitoring, offered in a group setting, designed to help the recipient develop or improve specific self-care, self-direction, communication, or social-interaction skills necessary for successful community adjustment and interaction with persons in the recipient’s home, school, work, or community environment; (26) "home and community-based waiver services" means services provided under AS 47.07.045 and 7 AAC 130; (27) "home and community-based waiver services provider" means a provider that the department has enrolled under 7 AAC 130.220 to provide one or more home and community-based waiver services; (28) "hospice care" has the meaning given in AS 47.07.900; (29) "hospital" means a facility licensed by the department under 7 AAC 12 to provide inpatient and outpatient hospital services; (30) "ICF" means an intermediate care facility;


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(31) "ICF/MR" means an intermediate care facility for the mentally retarded; (32) "individual psychotherapy" means any form of treatment for mental illness, behavioral maladaptation, or other problems that are assumed to be of an emotional nature, in which a trained individual deliberately establishes a professional relationship with an individual for the purpose of removing, modifying, or retarding existing symptoms, attenuating or reversing disturbed patterns of behavior, and promoting positive personality growth and development; (33) "individual skill development services" means face-to-face therapeutic self-care and life skill instruction, skill practice, and skill monitoring, provided to an individual, and designed to help the recipient develop or improve specific self-care skills, engage in age-appropriate social behavior, maintain the recipient’s household, and develop the ability to be independent within the recipient’s community; (34) "inpatient interdisciplinary team" means a team composed of physicians and other personnel who are employed by an inpatient psychiatric hospital facility, a residential psychiatric treatment center, or an individual who renders services to recipients in either facility; (35) "inpatient psychiatric hospital" means a hospital or part of a hospital, other than a residential psychiatric treatment center, that delivers medical and inpatient psychiatric services described in 7 AAC 12.215; (36) "inpatient psychiatric services" means diagnostic and treatment services for mental, behavioral, and emotional disorders provided in an inpatient psychiatric hospital that meets the conditions for payment under 7 AAC 140.350, or provided in a residential psychiatric treatment center that meets the conditions for payment under 7 AAC 140.400; (37) "intake assessment" means a systematic evaluation of a recipient upon admission to services, and periodically during the course of treatment, to assess and document mental status, social and medical history, the presenting problems and related symptoms, the recipient’s strengths and resources, and service needs of the recipient for the purposes of establishing a diagnosis and developing an individualized treatment plan; (38) "intermediate care facility" means a nursing facility that provides intermediate care services described in 7 AAC 140.510; "intermediate care facility" does not include an intermediate care facility for the mentally retarded; (39) "intermediate care facility for the mentally retarded" means a facility, or a distinct part of one, that

(A) is licensed under AS 47.32; (B) is primarily for the diagnosis, treatment, or rehabilitation of the mentally retarded or persons with related conditions; and (C) has met the conditions for payment under 7 AAC 140.600;

(40) "jurisdiction" means a state or territory of the United States and the District of Columbia; (41) "legend drug" has the meaning given in AS 08.80.480; (42) "long-term care" means

(A) services provided in a nursing facility; (B) services provided in an intermediate care facility for the mentally retarded;


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(C) home and community-based waiver services; or (D) any other services received in a medical institution by a recipient who is an institutionalized individual required to pay a portion of that individual’s income toward the cost of care under 7 AAC 100.550 - 7 AAC 100.579;

(43) "long-term care facility" means an intermediate care facility for the mentally retarded or a nursing facility; (44) "Medicaid" means the medical assistance program administered by the department under 42 U.S.C. 1396 - 1396v and AS 47.07, including those eligibility groups and services for which additional federal financial participation is available under 42 U.S.C. 1397a(a); (45) "medical institution" has the meaning given in 7 AAC 100.990; (46) "Medicare" means the medical assistance program administered by the federal government through private health insurance companies under 42 U.S.C. 1395 - 1395iii; (47) "Medicare cost report" means the uniform cost report that a facility must prepare under 42 C.F.R. 413.20 - 413.24; (48) "mental health clinical associate" has the meaning given in 7 AAC 43.1990; (49) "mental health professional clinician" has the meaning given in 7 AAC 43.1990; (50) "nursing facility" has the meaning given in AS 18.20.390; "nursing facility" includes a skilled nursing facility and an intermediate care facility; (51) "part A of Medicare" means that portion of the Medicare program providing coverage for hospital care under 42 U.S.C. 1395c - 1395i-5; (52) "patient" means an individual who receives medical attention, care, or treatment; (53) "person" has the meaning given in AS 01.10.060; "person" includes a municipality and the state; (54) "pharmacologic management" means assessing a recipient’s need for pharmacotherapy and prescribing appropriate medications to meet the recipient’s need, by a physician, a physician’s assistant, or an advanced nurse practitioner with prescriptive authority, and monitoring the recipient’s response to medication by appropriately licensed medical professionals, including documentation of medication compliance, assessment and documentation of side effects, and evaluation and documentation regarding the effectiveness of the medication; (55) "physiatrist" means a physician who specializes in that branch of medicine using physical therapy, physical agents, such as light, heat, water, and electricity, and mechanical apparatus, in the diagnosis, prevention, and treatment of bodily disorders known as physiatrics; (56) "prescription drug" has the meaning given in AS 08.80.480; (57) "primary care" means the provision of professional comprehensive health services that includes health education and disease prevention, initial assessment of health problems, treatment of acute and chronic health problems, and the overall management of an individual’s or family’s health care services; (58) "prior authorization" means approval by the department, in


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accordance with 7 AAC 105.130 and service-specific requirements in 7 AAC 43 and 7 AAC 105 - 7 AAC 160, of a certain type and number of units of Medicaid-covered services before those services are provided; (59) "provider" means an individual, firm, corporation, association, or institution that provides, medical assistance to a recipient under Medicaid; (60) "psychiatric assessment" means a systematic evaluation of a recipient to determine symptomatology, establish a diagnosis, and prescribe needed treatment; (61) "psychiatric facility" means a licensed hospital facility or part of a licensed hospital facility that is primarily for the diagnosis and treatment of mental, emotional, or behavioral disorders; (62) "psychiatrist" means a physician licensed to practice medicine in the jurisdiction in which services are provided, and who has completed a fully qualified residency in psychiatry; (63) "psychological associate" means an individual licensed in the jurisdiction in which services are provided, who renders specific mental health services in association with a licensed psychologist within the scope of practice identified in 12 AAC 60.185; (64) "psychological testing and evaluation" means the administration of standardized psychological tests and interpretation of findings by a psychologist, a psychological associate, or another mental health professional clinician with appropriate education and training, for the purpose of providing assistance in the psychiatric diagnosis of mental and emotional disorders or the assessment of functional capabilities; (65) "psychologist" means an individual who is licensed to practice psychology in the jurisdiction in which services are provided; (66) "psychosocial assessment" has the meaning given in this section for "functional assessment"; (67) "quality improvement organization" or "QIO" means an organization that has a contract with the Department of Health and Human Services, Centers for Medicare and Medicaid Services, under part B of title XI of the Social Security Act, 42 U.S.C. 1320c – 1320c-12, to perform utilization and quality control review of the health care furnished, or to be furnished, to Medicare beneficiaries, and operates under a contract with the state to provide preadmission screening and utilization review services; (68) "RBRVS" means resource-based relative value scale; (69) "recipient" means an individual who has been determined eligible for Medicaid in this state, including home and community-based waiver services, and who is receiving, is authorized to receive, or has received a Medicaid-covered service from a provider enrolled in the Medicaid program in this state; (70) "recipient’s representative" means a parent, guardian, or other individual with legal authority to act on the recipient’s behalf; (71) "recoupment" means an action by the department to recover an overpayment by reducing future payments to the provider until the amount of the overpayment has been offset; (72) "rendering provider" means a provider whose direct services are paid through a health care provider enrolled under 7 AAC 105.200(a); (73) "residential care" means a residential living arrangement that provides a structured setting with supervision and care where the needs of the residents


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are largely social; a facility providing residential care is one that offers (A) shelter, food, household maintenance, encouragement, and assistance to the residents; (B) guidance as necessary in activities of daily living; (C) social and recreational activities and opportunities; and (D) arrangements made to secure medical services when the need is indicated;

(74) "residential psychiatric treatment center" means a freestanding facility that

(A) provides residential child care and inpatient psychiatric services for the diagnosis and treatment of child and adolescent mental, emotional, or behavioral disorders; (B) is licensed under AS 47.32; (C) meets the requirements of 7 AAC 140.400; and (D) is not a provider eligible for payment under 7 AAC 150;

(75) "respite care" means care provided to an individual for the purpose of relief of family members or other regular care providers in the home, except for personal care assistants; (76) "rural health clinic" means a facility that has filed an agreement with the department to provide rural health clinic services under Medicaid; (77) "RVU" means relative value unit; (78) "service" means a medical evaluation or procedure, drug, medical supply, item, equipment, transportation, or other benefit related to an individual’s health or delivery of health care; (79) "skilled nursing facility" has the meaning given in 42 U.S.C. 1395i-3(a); (80) "SNF" means a skilled nursing facility; (81) "tribal health program" means a hospital, clinic, or other type of health care facility or program operated by

(A) the United States Department of Health and Human Services, Indian Health Service; (B) an Indian tribe as defined in 25 U.S.C. 450b(e) and 458aaa(b); (C) a tribal organization as defined in 25 U.S.C. 450b(l); or (D) an inter-tribal consortium as defined in 25 U.S.C. 458aaa(a)(5) or established by federal law;

(82) "utilization review" means the process of evaluating the appropriateness and efficient use of medical services and facilities, including admission criteria, length of stay, and discharge practices. (Eff. 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.040 AS 47.07.055


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Department Note on Integrated Behavioral Health Regulations: Medicaid coverage and payment regulations regarding mental health clinic services and substance abuse rehabilitation services were not included in the final version of the omnibus Medicaid coverage and payment regulations project that created 7 AAC 105 - 7 AAC 160, except for some conforming amendments to make the necessary cross-references to those new chapters. The following regulations are all that remain of 7 AAC 43 and these will soon be replaced with new Medicaid behavioral health regulations to be located in a new chapter 7 AAC 135 as part of the department's integrated behavioral health regulations initiative.

Chapter 43 Medical Assistance

Remaining Articles 6. Children's Services. (7 AAC 43.470 - 7 AAC 43.471) 7. Mental Health Services. (7 AAC 43.472 - 7 AAC 43.481) 8. Authorization of Mental Health Rehabilitation Services. (7 AAC 43.484 - 7 AAC

43.488) 15. Mental Health Clinic Services. (7 AAC 43.725 - 7 AAC 43.728) 16. Rates for Mental Health Services. (7 AAC 43.729) 17. Mental Health Rehabilitation Services. (7 AAC 43.734 - 7 AAC 43.739) 18. Substance Abuse Rehabilitative Services. (7 AAC 43.740 - 7 AAC 43.746) 34. Definitions. (7 AAC 43.1990)

Article 6 Children's Services

Section 470. Children's mental health services. 471. Severely emotionally disturbed children. 7 AAC 43.470. Children's mental health services. (a) The division will reimburse an enrolled provider for an intake assessment, a psychiatric assessment, or psychological testing and evaluation provided to a recipient under 21 years of age if a mental health professional reasonably believes the recipient is an emotionally disturbed child, or a severely emotionally disturbed child. (b) The division will reimburse an enrolled provider for Medicaid-covered mental health services provided to a Medicaid recipient under 21 years of age, if those services meet the requirements of 7 AAC 43.470 - 7 AAC 43.488, and 7 AAC 43.725 - 7 AAC 43.739. (c) Subject to the limits set out in 7 AAC 43.727, the division will reimburse a provider for mental health services provided to a recipient under 21 years of age if the (1) recipient is determined through an intake assessment, a psychiatric assessment, or psychological testing and evaluation to be an emotionally disturbed child; and (2) intake assessment indicates the recipient needs one or more of the following mental health clinic services:


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(A) crisis intervention, as described in 7 AAC 43.738; (B) family psychotherapy; (C) group psychotherapy; (D) individual psychotherapy; (E) pharmacologic management.

(d) If, at any time during the assessment, evaluation, or treatment of a recipient who is an emotionally disturbed child, an enrolled provider of mental health services determines that the recipient may be a severely emotionally disturbed child, and the recipient is in need of mental health rehabilitation services, that provider shall refer the recipient to a community mental health clinic that provides mental health rehabilitation services in the community. (e) Subject to the requirements of this section, the division will reimburse a community mental health clinic for the following mental health rehabilitation services under 7 AAC 43.734 provided to a recipient who is a severely emotionally disturbed child at risk of placement in a mental health inpatient or residential facility, group home, foster home, or similar out-of-home placement: (1) medication administration services, as described in 7 AAC 43.739, if the recipient is receiving at least one other mental health rehabilitation service; (2) a functional assessment, as described in 7 AAC 43.735; (3) case management, as described in 7 AAC 43.737; (4) family skill development services, as described in 7 AAC 43.472; (5) individual skill development services, as described in 7 AAC 43.736; (6) group skill development services, as described in 7 AAC 43.474; (7) day treatment services, as described in 7 AAC 43.476; (8) recipient support services, as described in 7 AAC 43.478; (9) the mental health clinic services listed in (c) of this section. (f) The severely emotionally disturbed child who receives mental health rehabilitative services listed in (e) of this section must be (1) provided with an intake assessment and a functional assessment; (2) provided with an EPSDT screening in accordance with 7 AAC 110.200 - 7 AAC 110.210; and (3) assigned an interdisciplinary team. (g) The division will reimburse a provider for the services identified in (e) of this section if those services are recommended by the recipient's interdisciplinary team, are included in the recipient's individualized treatment plan and clinical record, as developed under 7 AAC 43.728, and are provided as active treatment. If the services exceed the limits in 7 AAC 43.727, the services must also receive prior authorization by the division to determine whether they are medically necessary, as described in 7 AAC 43.486. (h) After its initial meeting, a recipient's interdisciplinary team shall meet at least quarterly while the recipient remains in treatment, and conduct a treatment plan review, as developed under 7 AAC 43.728(f), to review the recipient's individualized treatment plan and the effectiveness of the services being provided under that plan. The interdisciplinary team shall record the results of the review and any changes in the individualized treatment plan in the recipient's clinical record.


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(i) The division will reimburse case management services provided by the case manager assigned to the recipient for time spent setting up, traveling to, and attending the interdisciplinary team meeting. (j) The division will not reimburse a member of an interdisciplinary team, other than a case manager as provided in (i) of this section, for (1) travel to or from a meeting; (2) time spent in or preparing for a meeting; (3) serving as a member of an interdisciplinary team; or (4) writing or monitoring an individualized treatment plan. (k) An interdisciplinary team must include, at a minimum, (1) the recipient; (2) the recipient's family members, including parents, guardians, siblings, or others similarly involved in providing general oversight of the recipient; (3) a psychiatrist, psychologist, or mental health professional clinician; (4) the recipient's mental health provider, if different from the mental health professional clinician; (5) a staff member of the division of family and youth services in the department, if the recipient is in the state's custody or is under state supervision by the division of family and youth services; (6) a staff member of the division of juvenile justice in the department, if that division is involved with the care of the recipient; (7) if the recipient currently resides within an alternative living arrangement, including foster care, residential child care, or an institution, a representative of that facility; (8) if the recipient is currently unable to succeed in a school, a representative from the recipient's public, private, or home educational system, including a teacher, special education consultant, speech therapist, or other representative involved in the recipient's education; and (9) the case manager. (l) All members of the interdisciplinary team shall attend meetings of the team in person or by telephone and be involved in team decisions unless the clinical record documents that (1) the other team members determine that participation by the recipient or other individual involved with the care of the recipient is detrimental to the recipient's well being; (2) family members, school district employees, or government agency employees refuse to participate after the provider's diligent efforts to encourage participation; or (3) weather, illness, or another circumstance beyond a member's control prohibits that member from participating. (m) If a provision of this chapter requires the approval, concurrence, or recommendation of the interdisciplinary team, the interdisciplinary team may issue that approval, concurrence, or recommendation only upon the concurrence of (1) each team member under (k)(3) of this section; (2) the recipient or the recipient's representative; and


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(3) a majority of the team members other than the members identified in (1) and (2) of this subsection. (n) The provider shall notify all absent members of the proceedings and decisions of the interdisciplinary team meeting. (o) Repealed 2/1/2010. (Eff. 8/6/92, Register 123; am 12/31/92, Register 124; am 12/31/94, Register 132; readopt 8/7/96, Register 139; am 1/14/2000, Register 153; am 11/1/2000, Register 156; am 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 Editor's note: 7 AAC 43.470 originally took effect as emergency regulation 7 AAC 43.457 as set out in Register 123, October 1992. Before this section was made permanent in Register 124, January 1993, it was revised and renumbered to 7 AAC 43.470. Effective 8/7/96, Register 139, the Department of Health and Social Services readopted 7 AAC 43.470 in its entirety, without change, under AS 47.05 and AS\n 47.07. Executive Order No. 72 transferred certain rate-setting authority to the department. 7 AAC 43.471. Severely emotionally disturbed children. (a) A severely emotionally disturbed child must meet the following criteria: (1) the recipient's specific symptoms and maladaptive behavior are identified and documented in the clinical record through an intake assessment and functional assessment, and provide the basis for the recipient's diagnosis; (2) the recipient has, as a result of the recipient's symptoms and maladaptive behavior, serious functional impairment in one or more areas of social functioning, including family, school, or community, as indicated by

(A) an Axis V Global Assessment of Functioning (GAF) rating at admission of 50 or less under the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, dated 2000 (DSM-IV-TR), adopted by reference; or (B) the exhibition of specific mental, behavioral, or emotional disorders that place the recipient at imminent risk for out-of-home supervision or protective custody by state or local authorities;

(3) the clinical record confirms that the recipient's symptoms and maladaptive behavior have lasted at least six months, and the symptoms and maladaptive behavior require mental health rehabilitation services that are medically necessary, as determined in accordance with 7 AAC 43.486; (4) the recipient's symptoms and maladaptive behavior are not a result of intellectual, physical, or sensory deficits; (5) the recipient's treatment planning process requires active collaboration of the interdisciplinary team required under 7 AAC 43.470; and (6) the recipient's clinical record documents that the interdisciplinary team required under 7 AAC 43.470 has recommended and approved, in accordance with that section, the mental health clinic services and rehabilitation services specified in the individualized treatment plan. (b) Repealed 2/1/2010. (Eff. 11/1/2000, Register 156; am 4/28/2005, Register 174; am 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040


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Editor's note: The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, dated 2000 and adopted by reference in 7 AAC 43.471, may be obtained from the American Medical Association at (800) 621-8335; from American Psychiatric Publishing, Inc., 1000 Wilson Boulevard, Suite 1825, Arlington, Virginia 22209-3901, telephone (703) 907-7322 or (800) 368-5777; or from the American Psychiatric Association at the following electronic mail address: [email protected]. This manual is also available for inspection at the Department of Health and Social Services, Division of Health Care Services, 4501 Business Park Boulevard, Suite 24, Anchorage, Alaska 99503-7167.

Article 7 Mental Health Services

Section 472. Family skill development services. 474. Group skill development services. 476. Day treatment services. 478. Recipient support services. 481. Behavioral rehabilitation services. 7 AAC 43.472. Family skill development services. (a) The division will reimburse a community mental health clinic for family skill development services provided to a recipient in accordance with 7 AAC 43.470(f) and to the recipient's family, if the recipient is present for part of each session. (b) The division will not reimburse a community mental health clinic for travel costs or time of travel to or from a recipient's home. (c) Family skill development services may not be provided to more than one family during the same session by the same service provider. (d) The division will not reimburse a provider for family skill development services that exceed 180 hours per recipient per calendar year without prior authorization under 7 AAC 43.484. (e) The division will reimburse a provider for family skill development services at the rate specified for that service in 7 AAC 43.729 and subject to the service limitations in 7 AAC 43.727. (Eff. 8/6/92, Register 123; am 12/31/92, Register 124; am 12/31/94, Register 132; am 3/13/96, Register 137; readopt 8/7/96, Register 139; am 11/1/2000, Register 156 Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 Editor's note: 7 AAC 43.472 originally took effect as emergency regulation 7 AAC 43.458 as set out in Register 123, October 1992. Before this section was made permanent in Register 124, January 1993, it was revised and renumbered to 7 AAC 43.472. Effective 8/7/96, Register 139, the Department of Health and Social Services readopted 7 AAC 43.472 in its entirety, without change, under AS 47.05 and AS 47.07. Executive Order No. 72 transferred certain rate-setting authority to the department. 7 AAC 43.474. Group skill development services. (a) The division will reimburse a community mental health clinic for group skill development services provided to a recipient in accordance with 7 AAC 43.470(f) or 7 AAC 43.734(d).


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(b) The minimum staff ratio for group skill development services is one qualified staff individual for each six recipients, with one additional staff member for one or more recipients in excess of the nearest multiple of six. (c) Group skill development services may be provided within a clinic, school, or any other appropriate community setting specified in the individualized treatment plan. (d) The division will not reimburse a provider for group skill development services that exceed 140 hours per recipient per calendar year without prior authorization under 7 AAC 43.484. (e) The division will reimburse a provider for group skill development services at the rate specified for that service in 7 AAC 43.729 and subject to the service limitations in 7 AAC 43.727. (Eff. 8/6/92, Register 123; am 12/31/92, Register 124; am 12/31/94, Register 132; am 3/13/96, Register 137; readopt 8/7/96, Register 139; am 11/1/2000, Register 156 Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 Editor's note: 7 AAC 43.474 originally took effect as emergency regulation 7 AAC 43.459 as set out in Register 123, October 1992. Before this section was made permanent in Register 124, January 1993, it was revised and renumbered to 7 AAC 43.474. Effective 8/7/96, Register 139, the Department of Health and Social Services readopted 7 AAC 43.474 in its entirety, without change, under AS 47.05 and AS 47.07. Executive Order No. 72 transferred certain rate-setting authority to the department. 7 AAC 43.476. Day treatment services. (a) The division will reimburse a community mental health clinic for day treatment services provided to a recipient in accordance with 7 AAC 43.470(f). (b) Day treatment services must be provided as a mental health service within a school district program that combines both therapeutic and academic activities. The therapeutic component may be reimbursed if recommended as required in 7 AAC 43.734(d)(2), according to the recipient's individualized treatment plan. The academic component must be provided by appropriately trained and experienced school district staff, according to the recipient's individualized education program developed under 4 AAC 52.140. The individualized treatment plan must include specific short-term goals to increase the recipient's ability to adapt to the school environment and progress academically. (c) The community mental health clinic providing day treatment services must establish with the local school district a written agreement that specifies the day treatment program's goals, eligibility guidelines, admission and discharge criteria and procedures, roles and responsibilities of the parties to the agreement and the resources contributed by each of the parties to the agreement. (d) Day treatment services must be provided within the recipient's school setting. (e) The division will not reimburse a provider for day treatment services that exceed 30 full days of service or 60 half days of service per recipient per calendar year, without prior authorization under 7 AAC 43.484. (Eff. 8/6/92, Register 123; am 12/31/92, Register 124; am 12/31/94, Register 132; am 3/13/96, Register 137; readopt 8/7/96, Register 139; am 11/1/2000, Register 156 Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040


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Editor's note: 7 AAC 43.476 originally took effect as emergency regulation 7 AAC 43.460 as set out in Register 123, October 1992. Before this section was made permanent in Register 124, January 1993, it was revised and renumbered to 7 AAC 43.476. Effective 8/7/96, Register 139, the Department of Health and Social Services readopted 7 AAC 43.476 in its entirety, without change, under AS 47.05 and AS 47.07. Executive Order No. 72 transferred certain rate-setting authority to the department. 7 AAC 43.478. Recipient support services. (a) The division will reimburse a community mental health clinic for recipient support services provided to a child in accordance with 7 AAC 43.470(f) or to an adult in accordance with 7 AAC 43.734(d). The community mental health clinic must receive prior authorization from the division in accordance with 7 AAC 43.484. (b) Recipient support services may be provided within the home, workplace, school, or any other appropriate community setting specified in the individualized treatment plan. (c) Recipient support services may be provided to more than one recipient during the same session by the same service provider, if the additional recipients live in the same household as the recipient and the service is provided to recipients who live in that household. (d) The division will not reimburse a provider for recipient support services that exceed four hours per day per recipient, without prior authorization under 7 AAC 43.484. (Eff. 8/6/92, Register 123; am 12/31/92, Register 124; am 12/31/94, Register 132; readopt 8/7/96, Register 139; am 11/1/2000, Register 156 Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 Editor's note: 7 AAC 43.478 originally took effect as emergency regulation 7 AAC 43.461 as set out in Register 123, October 1992. Before this section was made permanent in Register 124, January 1993, it was revised and renumbered to 7 AAC 43.478. Effective 8/7/96, Register 139, the Department of Health and Social Services readopted 7 AAC 43.478 in its entirety, without change, under AS 47.05 and AS 47.07. Executive Order No. 72 transferred certain rate-setting authority to the department. 7 AAC 43.481. Behavioral rehabilitation services. (a) In order to enroll and to provide behavioral rehabilitation services, a provider must be a grantee of the department under 7 AAC 53.901. (b) Behavioral rehabilitation services (1) must be approved by the department; (2) may only be provided

(A) to a severely emotionally disturbed child under 7 AAC 43.471; (B) if recommended by or under the direction of a licensed physician or licensed mental health professional clinician; and (C) if they are designed to remediate problems associated with a mental health diagnosis that is documented in a clinical assessment, and if they are specifically identified in an individualized treatment plan developed, reviewed, and updated in accordance with 7 AAC 43.728;

(3) that consist of supportive counseling must be consistent with the severely emotionally disturbed child's individualized treatment plan developed, reviewed,


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and updated in accordance with 7 AAC 43.728; counseling must be documented and made available to a licensed physician or licensed mental health professional clinician for review; and (4) may be provided in a residential care, therapeutic foster care, or therapeutic group home setting. (c) The department will pay for behavioral rehabilitation services in accordance with 7 AAC 43.729(c). The levels of behavioral rehabilitation services for which the department will pay, set out in the department's Behavioral Rehabilitation Services Handbook, 2005 edition, are adopted by reference. (d) A severely emotionally disturbed child who has been approved to receive behavioral rehabilitation services is not eligible to receive mental health rehabilitation services provided under 7 AAC 43.470(e) on the same dates of service. A severely emotionally disturbed child who is receiving behavioral rehabilitation services remains eligible to receive mental health clinic services described in 7 AAC 43.470(c). (e) In this section "behavioral rehabilitation services" means early intervention and stabilization services to help severely emotionally disturbed children develop essential and appropriate coping skills. "Behavioral rehabilitation services" includes (1) milieu therapy; (2) crisis counseling to assist a severely emotionally disturbed child to resolve an immediate, pressing problem and to screen the child for referral to a mental health professional for further assessment and intervention; (3) supportive counseling in accordance with (b)(3) of this section; (4) skills training; and (5) case management. (Eff. 12/16/2005, Register 176 Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 Editor's note: The Behavioral Rehabilitation Services Handbook, adopted by reference in 7 AAC 43.481, may be obtained from the Department of Health and Social Services, Division of Behavioral Health, P.O. Box 110620, Juneau, Alaska 99811-0620, or on the department's website at the following Internet address: http://www.hss.state.ak.us/dbh.

Article 8 Authorization of Mental Health Rehabilitation Services

Section 484. Prior authorization of mental health rehabilitation services. 486. Medical necessity determinations for mental health rehabilitation services. 488. Extension of service limitations in exceptional circumstances. 7 AAC 43.484. Prior authorization of mental health rehabilitation services. A provider request for prior authorization of an extension of a service beyond service limitations, or a provider request for a change in the level of the service that a recipient previously received, must be made in writing on the form approved by the division, and must be received by the division 15 days before the end of the current approved period of service. The request must (1) be documented in the clinical record prepared under 7 AAC 43.728;


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(2) include a listing of all Medicaid reimbursable services and the expected duration of these services as set out in the recipient's individualized treatment plan; and (3) affirm that the recipient's interdisciplinary team in accordance with 7 AAC 43.470, if the recipient is a severely emotionally disturbed child, or the recipient's physician or mental health professional clinician, if the recipient is a severely emotionally disturbed adult or a chronically mentally ill adult, has reviewed the treatment plan and recommended the requested services as medically necessary. (Eff. 11/1/2000, Register 156 Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 7 AAC 43.486. Medical necessity determinations for mental health rehabilitation services. (a) The division will, in its discretion, periodically review the recipient's clinical record to determine whether the services requested are medically necessary. A medically necessary mental health rehabilitation service is a service designed to (1) screen recipients for the presence of a mental or emotional disorder; (2) assess the nature and extent of the mental or emotional disorder and its impact upon the recipient's ability to meet the demands of daily living, social, occupational, or educational functioning; (3) diagnose the mental or emotional disorder; (4) treat the mental or emotional disorder; (5) provide rehabilitation for the mental or emotional disorder; (6) prevent the relapse or deterioration of the recipient's condition due to the mental or emotional disorder. (b) In making its determination as to whether the proposed services are medically necessary, the division will consider the following: (1) the recommendations of the referring physician, mental health professional clinician, or interdisciplinary team organized under 7 AAC 43.470 that prescribed, ordered, recommended, or approved the service; (2) the recipient's diagnosis and level of functioning; (3) the risk of danger from the recipient to self or other individuals; (4) the appropriateness of the level of care and the need for inpatient or residential care; (5) whether the intervention targets specific symptoms and behavioral and social dysfunction, and logically derives from the assessments and diagnosis; (6) whether the proposed services in the individualized treatment plan are consistent with generally accepted community-based treatments and practices for the treatment of the specific symptoms and behavioral and social dysfunction; (7) whether the recipient agrees with the referring physician, mental health professional clinician, or interdisciplinary team under (1) of this subsection that the focus of the treatment will be the symptoms and behavioral and social dysfunction targeted for intervention; (8) the extent to which past and current treatment has been successful in treating the symptoms and behavioral and social dysfunction;


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(9) if the recipient is under 21 years of age, whether the recipient has, as indicated by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, dated 2000, an Axis V Global Assessment of Functioning (GAF) rating at admission of 50 or less, or the recipient has an Axis V Global Assessment of Functioning (GAF) rating at admission of more than 50, but exhibits specific mental, behavioral, or emotional disorders that place the recipient at imminent risk for out-of-home supervision or protective custody of state or local authorities; the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, dated 2000, is adopted by reference; (10) the extent to which a less restrictive or intrusive alternative treatment is not available; (11) the extent to which a less expensive alternative is not available; (12) the extent to which the units of service requested are no more than are necessary to meet the treatment or rehabilitation needs of the recipient; (13) the extent to which the duration of services requested are no more than are necessary to reach the recipient-approved goals outlined in the individualized treatment plan; (14) if the requested services are intended to prevent the relapse or deterioration of a mental disorder, the extent to which social functioning is improved through interventions provided as active treatment, targeted in specific therapeutic goals, and included in the individualized treatment plan; (15) the likelihood that the recipient will benefit from any therapy provided on the same day as the recipient has received crisis intervention services. (c) Payment for services determined not to be medically necessary under this section is subject to recovery under 7 AAC 105.260. (Eff. 11/1/2000, Register 156; am 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 Editor's note: The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, dated 2000 and adopted by reference in 7 AAC 43.486, may be obtained by writing to the American Psychiatric Association, 1400 K Street, N.W., Washington, D.C. 20005. This manual is also available for inspection at the Department of Health and Social Services, Division of Behavioral Health, 3601 C Street, Suite 878, Anchorage, Alaska. 7 AAC 43.488. Extension of service limitations in exceptional circumstances. (a) The director will authorize the extension of a service limitation set out in 7 AAC 43.727 for a mental health clinic service, if the director determines that exceptional circumstances exist. (b) For purposes of (a) of this section, the director will not determine that exceptional circumstances exist unless the director, upon the provider's request or at the director's own initiative, determines that the factual circumstances justifying the extension rarely arise and that an extension is necessary to protect a recipient's health. When considering an extension under (a) of this section, the director will consider (1) the area or region of the state where the service is provided; (2) the provider's business location;


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(3) for an individualized treatment plan in existence before November 1, 2000, the length of time necessary to revise or replace the individualized treatment plan so that the plan conforms to the requirements of 7 AAC 43.727; and (4) whether the recipient is served by more than one provider. (c) An extension under (a) of this section is valid through the date designated by the director. (Eff. 11/1/2000, Register 156 Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040

Article 15 Mental Health Clinic Services

Section 725. Conditions for payment. 726. Coverage for mental health clinic services. 727. Service limitations. 728. Clinical records, treatment plans, and assessments. 7 AAC 43.725. Conditions for payment. (a) To be eligible for Medicaid reimbursement, a mental health clinic must be a (1) community mental health clinic that meets the requirements of (b) of this section; or (2) mental health physician clinic that meets the requirements of (b) and (c) of this section. (b) To be eligible for Medicaid reimbursement, a mental health clinic must be administratively, organizationally, financially, and otherwise separate from a health facility, as defined in AS 47.07.900, except that (1) a governmental or corporate entity may concurrently operate a mental health clinic and a health facility in the same building or in separate locations if

(A) the health facility's administrator and governing board have no administrative or financial authority over the mental health clinic; and (B) all expenses and income of the mental health clinic are accounted for separately from the expenses and income of the health facility so that the costs of operating the mental health clinic are excluded from the costs considered by the department in determining the health facility's prospective payment rate under 7 AAC 150;

(2) a mental health clinic operated by a governmental or corporate entity that concurrently operates a health facility may enter into a written agreement with the health facility under which the health facility is to provide administrative and other support services, except supervision of the mental health clinic, to the mental health clinic, subject to the following limitations:

(A) if the health facility charges the mental health clinic for a service provided by the health facility, the charge must be based on the direct cost incurred by the health facility for providing the service; (B) if the health facility does not charge the mental health clinic for a service provided, the costs incurred by the health facility in providing the


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service will be excluded from the costs considered by the department in determining the health facility's prospective payment rate under 7 AAC 150; and (C) a mental health clinic may not obtain the services of the supervising psychiatrist required under subsection (c) through an agreement with a health facility;

(3) a physician or other health professional who is employed by a health facility operated by a governmental or corporate entity that concurrently operates a mental health clinic may also be employed, under a separate written agreement, by the mental health clinic only if

(A) the services provided under the employment agreement do not include those of the supervising psychiatrist required by subsection (c); (B) the cost of services provided by this employee is separately accounted for by the mental health clinic; and (C) the cost of services provided by this employee is excluded from the costs considered by the department in determining the health facility's prospective payment rate under 7 AAC 150; and

(4) a physician or other health professional who provides services under a contract or other agreement to a health facility that is operated by a governmental or corporate entity that concurrently operates a mental health clinic may also provide services to the mental health clinic under a separate agreement with the mental health clinic only if the costs of the services provided are separately accounted for by the mental health clinic and are excluded from the costs considered by the department in determining the health facility prospective payment rate under 7 AAC 150. (c) The division will reimburse for mental health clinic services provided by a mental health physician clinic only if (1) the services are provided by a psychiatrist or by a mental health professional clinician working under the direct supervision of a psychiatrist; (2) the psychiatrist operating the clinic provides direct supervision, as described in 7 AAC 43.1990, to all service providers in the clinic and assumes responsibility for the treatment given; and (3) necessary adjunctive treatment is provided either directly or through a written agreement with another qualified mental health professional clinician. (d) To qualify for reimbursement under 7 AAC 43.470 - 7 AAC 43.478 and 7 AAC 43.725 - 7 AAC 43.729, all mental health clinic services must be provided on the premises of the mental health clinic. (e) Notwithstanding the provisions of this section, 7 AAC 43.470 - 7 AAC 43.478, and 7 AAC 43.726 - 7 AAC 43.729, the division will reimburse a community mental health clinic for the services described in 7 AAC 43.470(a) and listed in 7 AAC 43.726(a) only upon certification by the division of mental health and developmental disabilities that the clinic operates in accordance with the provisions of 7 AAC 71. (Eff. 8/18/79, Register 71; am 5/5/93, Register 126; am 12/31/94, Register 132; readopt 8/7/96, Register 139; am 11/1/2000, Register 156; am 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 Editor's note: Effective 8/7/96, Register 139, the Department of Health and Social Services readopted 7 AAC 43.725 in its entirety, without change, under AS 47.05 and AS 47.07. Executive Order No. 72 transferred certain rate-setting authority to the department.


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7 AAC 43.726. Coverage for mental health clinic services. (a) Subject to the requirements of this section, the division will reimburse an eligible mental health clinic for the following mental health clinic services, provided to a recipient who is determined to be an emotionally disturbed child or an emotionally disturbed adult through an intake assessment, a psychiatric assessment, or psychological testing and evaluation administered under 7 AAC 43.470 or 7 AAC 43.734, if identified in the recipient's individualized treatment plan as medically necessary, in accordance with 7 AAC 43.486, and provided as active treatment: (1) crisis intervention, as described in 7 AAC 43.738; (2) family psychotherapy; (3) group psychotherapy; (4) individual psychotherapy; (5) pharmacologic management. (b) The division will reimburse a mental health clinic for (1) family psychotherapy, if at least a portion of the family psychotherapy session is attended by the family or household member eligible for Medicaid coverage under this chapter, and the therapist has at least the qualifications of a mental health professional clinician; (2) group psychotherapy, if at least one therapist is present for every 10 recipients in the group, and that therapist

(A) is participating in the therapy; and (B) has at least the qualifications of a mental health professional clinician;

(3) biofeedback or relaxation therapy as an element of individual psychotherapy, if it is

(A) prescribed by a psychiatrist, when provided in a mental health physician clinic, or prescribed by a physician or mental health professional clinician, when provided in a community mental health clinic; and (B) included in the individualized treatment plan as a recognized treatment or adjunct to a treatment for chronic pain syndrome, panic disorders, phobias, or similar conditions; and

(4) a psychiatric assessment, if the recipient enters into treatment, the recipient changes providers, or a change occurs in the recipient's medical condition that requires a new psychiatric assessment or an annual assessment; a psychiatric assessment must be

(A) rendered by a physician, a psychiatrist, or a physician assistant or psychiatric nurse practitioner working under the

(i) direct supervision of a psychiatrist, when the psychiatric assessment is provided in a mental health physician clinic; or (ii) general direction of a physician or a mental health professional clinician, when the psychiatric assessment is provided in a community mental health clinic;

(B) completed within one month of entry into treatment; and (C) updated at least annually.

(c) The division will not reimburse a provider for


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(1) outpatient mental health services provided by a hospital or psychiatric facility; (2) experimental therapy, outpatient therapy and counseling that is not medically necessary as determined in accordance with 7 AAC 43.486, therapy or counseling by telephone, telephone consultation with another service provider other than case management, preparation of reports, narcosynthesis, socialization, recreation therapy, primal therapy, rage reduction or holding therapy, marathon group therapy, megavitamin therapy, pastoral counseling, employment counseling, or explanation of an examination to a family member or other responsible individual that is provided outside of a family therapy session; (3) any therapy or evaluation if the documentation required by 7 AAC 43.728 is inadequate or is absent from the recipient's clinical record or individualized treatment plan; (4) room and board costs as a part of a mental health clinic service or rehabilitation service; or (5) transportation or travel time as a part of a mental health clinic service or rehabilitation service. (Eff. 8/18/78, Register 71; 5/5/93, Register 126; am 12/31/94, Register 132; readopt 8/7/96, Register 139; am 11/1/2000, Register 156 Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 Editor's note: Effective 8/7/96, Register 139, the Department of Health and Social Services readopted 7 AAC 43.726 in its entirety, without change, under AS 47.05 and AS 47.07. Executive Order No. 72 transferred certain rate-setting authority to the department. 7 AAC 43.727. Service limitations. (a) Reimbursement to providers for mental health clinic services without prior authorization by the division in accordance with 7 AAC 43.484, is limited to (1) any combination of individual, group, and family psychotherapy, no more than 10 hours in a calendar year; (2) no more than four psychiatric assessments per recipient during a calendar year; (3) psychological testing and evaluation, no more than six hours per recipient during a calendar year, except that neuropsychological testing and evaluation is limited to 12 hours per recipient in a calendar year if the provider documents in writing to the division the provider's qualifications to provide neuropsychological testing and evaluation services; (4) pharmacologic management, no more than one visit per week for the initial month following the recipient's entry into Medicaid-covered treatment, and, thereafter, no more than once per month, unless use of a specific medication requires more frequent monitoring or a recipient's unusual clinical reaction to a medication requires more frequent medication monitoring; (5) an intake assessment, upon admission to treatment, and consisting of one or more sessions that total no more than three hours in aggregate, and one intake assessment of no more than one hour in duration every six months that the recipient remains in continuous treatment; (6) case management, no more than 180 hours per recipient per calendar year;


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(7) individual skill development services, no more than (A) 100 hours per recipient under age 21, per calendar year; and (B) 240 hours per adult recipient, per calendar year;

(8) group skill development services, no more than 140 hours per calendar year; (9) family skill development, no more than 180 hours per calendar year; and (10) recipient support services, no more than four hours per day. (b) The division will reimburse a provider for crisis intervention, as described in 7 AAC 43.738, if (1) the total crisis intervention services provided to a recipient do not exceed 22 hours during a calendar year, or services in excess of 22 hours have been extended in accordance with 7 AAC 43.488; and (2) the services are provided during a brief psychiatric emergency of no more than 72 hours in duration, that is documented in the recipient's clinical record. (Eff. 5/5/93, Register 126; am 12/31/94, Register 132; am 3/13/96, Register 137; readopt 8/7/96, Register 139; am 11/1/2000, Register 156 Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 Editor's note: Effective 8/7/96, Register 139, the Department of Health and Social Services readopted 7 AAC 43.727 in its entirety, without change, under AS 47.05 and AS 47.07. Executive Order No. 72 transferred certain rate-setting authority to the department. 7 AAC 43.728. Clinical records, treatment plans, and assessments. (a) A provider of mental health services shall maintain a clinical record of services provided to a recipient. A clinical record must include (1) an intake assessment that meets the requirements of (e) and (f) of this section; (2) an individualized treatment plan that meets the requirements of (c) and (f) of this section; (3) a psychiatric assessment that meets the requirements of (d) and (f) of this section, if the services are provided at a mental health physician clinic; (4) a functional assessment, if the recipient receives mental health rehabilitation services in a community mental health clinic; (5) a progress note for each service for each day the service was provided, signed by the individual provider; the progress note must describe the credentials of the provider, the service provided, the date of the service, the duration of each service, and the recipient's progress toward identified treatment goals; and (6) the documentation of concurrence in accordance with 7 AAC 43.470 by any interdisciplinary team organized under that section for each extension of a rehabilitation service beyond the limits in 7 AAC 43.727. (b) A clinical record must include reports of the following services if provided to the recipient and reimbursed to a provider by the division: (1) a psychiatric assessment provided in a community mental health clinic; (2) a report describing the evaluation procedure and findings of any psychological testing and evaluation.


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(c) An individualized treatment plan must include (1) information identifying the recipient; (2) a list of the members of any interdisciplinary team organized under 7 AAC 43.470 participating in the planning and implementation of the plan; (3) a prioritized summary of the presenting problems and needs as stated by the recipient and identified during the intake and functional assessments; (4) a summary statement of the strengths and current resources of the recipient; (5) a diagnosis established through an intake assessment; (6) clearly stated goals and measurable objectives derived from the intake assessment and functional assessment and designed to accomplish specific, observable changes in skills, symptoms, behaviors, or circumstances that directly relate to a better quality of life for the recipient; (7) specific interventions, services, or activities that are designed to accomplish the stated goals or objectives, that promote active treatment, and that are medically necessary, as determined in accordance with 7 AAC 43.486; (8) the frequency and duration of each intervention, service, or activity included within the plan; (9) identification of the individual provider responsible for implementation of each of the plan's goals, interventions, and services; (10) locations where the intervention, service, or activity will be provided; (11) specific time periods for attainment of each goal or objective; (12) documentation that the recipient or the recipient's representative actively participated in the development of the treatment plan, or if active involvement is not possible, a statement of the reasons for the lack of participation; (13) signatures of the following individuals, indicating review and approval:

(A) the recipient or the recipient's representative, unless the recipient or the recipient's representative is not willing or able to participate as described in (12) of this subsection; (B) at least one physician or mental health professional clinician; (C) the case manager, if one is assigned; (D) those participating members of any interdisciplinary team organized under 7 AAC 43.470 who have reviewed and approved the plan; and

(14) a description of any need for an additional evaluation or assessment. (d) A psychiatric assessment must be rendered by a psychiatrist, a physician, a physician assistant, or a psychiatric nurse practitioner. (e) A psychiatrist or mental health professional clinician must complete a written intake assessment within one week after a recipient's entry into treatment, update the assessment as new information becomes available, and consider current psychiatric assessments, psychological testing and evaluation, and medical evaluations. The intake assessment must include (1) the recipient's name, date of birth, address, and other identifying information; (2) the recipient's current living arrangement and status;


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(3) information about and the status of the recipient's family or guardian; (4) an assessment of the strengths and needs of the recipient and the recipient's family; (5) the recipient's medical and psychiatric history and current status; (6) the recipient's medication use history and current status; (7) an assessment of the recipient's use of alcohol and other drugs; (8) an assessment of the recipient's mental status; (9) a complete DSM-IV diagnosis, as set out in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, dated 2000, adopted by reference; (10) a prognosis for the recipient; and (11) treatment and service recommendations. (f) Providers must perform a treatment plan review at least every three months for recipients under age 21 and at least every six months for recipients age 21 and over. The treatment plan review must include (1) the recipient's name, date of birth, address, and other identifying information; (2) the date of the review; (3) the period covered by the review; (4) any updated or new assessments completed during the review period; (5) any change in the recipient's diagnosis; (6) a brief analysis including

(A) the recipient's progress toward each goal established in the individualized treatment plan; (B) the effectiveness of the strategies or techniques recommended by the mental health professionals treating the recipient; (C) recommendations for and changes to treatment goals, objectives, strategies, interventions, frequency, or duration; (D) any change of individual providers, or any recommendation to change individual providers; and (E) the expected duration of the medical necessity for the recommended changes;

(7) an examination of the recommended individualized treatment plan for (A) the least restrictive setting and for services that are conducive to normal behavior; (B) discharge or transition criteria necessary to move the recipient to less restrictive services; and (C) satisfaction of the recipient and the recipient's legal representative, if any, with the treatment planning process, services provided, and progress toward established goals; and

(8) dated signatures from the (A) recipient or the recipient's legal representative; (B) primary mental health professional clinician; and (C) mental health professionals treating the recipient, with indication of appropriate credentials for any mental health professional clinicians and mental health clinical associates.


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(g) Subject to the other provisions of this subsection, a provider may satisfy the recordkeeping requirements of this section for records that contain behavioral health information through electronic records that meet the applicable requirements of 7 AAC 85. Notwithstanding the requirements of this section, a provider may be required to retain paper or paper-based copies of documents under other state or federal law for audit or other purposes. For purposes of this subsection, (1) "behavioral health information" means information regarding behavioral health services, including

(A) emergency services, including detoxification and acute psychiatric hospitalization; and (B) prevention, intervention, and treatment services in the areas of mental health and of alcohol abuse and other addictions, including ongoing care and supportive services; and

(2) "paper-based copies" means documents stored on microfilm or microfiche, in tagged image file format (TIFF), portable document file (PDF) format, or in another format that allows for the efficient storage of documents. (h) If a provider that is awarded a grant under 7 AAC 78 or 7 AAC 81 closes or ceases to exist as a service provider, the provider's records under that grant, including recipient records, are subject to the requirements of 7 AAC 78.255 or 7 AAC 81.185, as applicable. (Eff. 5/5/93, Register 126; am 12/31/94, Register 132; readopt 8/7/96, Register 139; am 11/1/2000, Register 156; am 9/23/2004, Register 171; am 2/1/2010, Register 193) Authority: AS 18.23.100 AS 47.07.030 AS 47.07.040 AS 47.05.010 Editor's note: The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, dated 2000 and adopted by reference in 7 AAC 43.728, may be obtained by writing to the American Psychiatric Association, 1400 K Street N.W., Washington, DC 20005. This manual is also available for inspection at the Department of Health and Social Services, Division of Behavioral Health, 3601 C Street, Suite 878, Anchorage, Alaska. Effective 8/7/96, Register 139, the Department of Health and Social Services readopted 7 AAC 43.728 in its entirety, without change, under AS 47.05 and AS 47.07. Executive Order No. 72 transferred certain rate-setting authority to the department.

Article 16 Rates for Mental Health Services

Section 729. Rates. 7 AAC 43.729. Rates. (a) The division will reimburse a provider for mental health clinic services and certain mental health rehabilitation services at the following rates: (1) for individual psychotherapy, the lesser of the fee normally charged the general public or $80 per hour; (2) for family psychotherapy, the lesser of the fee normally charged the general public or $80 per hour;


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(3) for group psychotherapy, the lesser of the fee normally charged the general public or $45 per session for each recipient eligible for payments under this chapter; (4) for individual skill development services provided as mental health rehabilitation services, $50 per hour; (5) for an intake assessment, $85 per hour, for a maximum of three hours per assessment; (6) for a psychiatric assessment, $230 per assessment, not to exceed four assessments in any calendar year; (7) for an initial functional assessment provided as a mental health rehabilitation service, $50 per hour for a maximum of four hours; (8) for a semi-annual functional assessment update provided as a mental health rehabilitation service, $50 per hour for a maximum of one hour; (9) for psychological testing and evaluation, the lesser of the fee normally charged the general public or $85 per hour; (10) for services provided out-of-state, reimbursement to providers at the Medicaid rate in the state where the service was provided; (11) for crisis intervention, $75 per hour for a maximum of two hours per day; (12) repealed 11/1/2000; (13) for case management provided as mental health rehabilitation services, $50 per hour; (14) for medication administration services provided

(A) on the premises of the community mental health clinic, $20 per day per recipient; or (B) in the recipient's home, or in any other appropriate location within the community that is necessary to ensure continuity of care, $30 per day per recipient;

(15) for group skill development services, $30 per hour per recipient; (16) for family skill development services, $50 per hour; (17) for day treatment services provided as mental health rehabilitation services

(A) $150 per day, for a minimum of six hours; or (B) $100 per half-day, for a minimum of three hours;

(18) for recipient support services provided as mental health rehabilitation services, $20 per hour; (19) for pharmacologic management, $75 per visit. (b) When, in compliance with licensing requirements established under 7 AAC 50.005 - 7 AAC 50.790, a community mental health clinic provides mental health rehabilitation services in a foster home or residential setting and the recipient's needs are defined in accordance with 7 AAC 53.060, the department will pay the community mental health clinic for the mental health rehabilitation services at the daily rate of $171 unless the recipient is in need of services requiring 24-hour supervision to alleviate maladaptive behavior or serious functional impairment. If the recipient is in need of services requiring 24-hour supervision to alleviate maladaptive behavior or serious functional impairment and prior approval has been obtained from the department,


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payment to the community mental health clinic will be made at the rates established in 7 AAC 43.729(a). (c) The daily rates identified for behavioral rehabilitation services in the department's Behavioral Rehabilitation Services Handbook, 2005 edition, are adopted by reference. The department will pay for behavioral rehabilitation services at those daily rates, not to include room and board. (Eff. 5/5/93, Register 126; am 12/31/94, Register 132; am 3/13/96, Register 137; readopt 8/7/96, Register 139; am 11/1/2000, Register 156; am 7/1/2004, Register 170; am 12/16/2005, Register 176 Authority: AS 47.05.010 AS 47.07.030 Editor's note: The Behavioral Rehabilitation Services Handbook, adopted by reference in 7 AAC 43.729, may be obtained from the Department of Health and Social Services, Division of Behavioral Health, P.O. Box 110620, Juneau, Alaska 99811-0620, or on the department's website at the following Internet address: http://www.hss.state.ak.us/dbh. Effective 8/7/96, Register 139, the Department of Health and Social Services readopted 7 AAC 43.729 in its entirety, without change, under AS 47.05 and AS 47.07. Executive Order No. 72 transferred certain rate-setting authority to the department.

Article 17 Mental Health Rehabilitation Services

Section 734. Mental health rehabilitation services. 735. Functional assessment. 736. Individual skill development services. 737. Case management. 738. Crisis intervention. 739. Medication administration services. 7 AAC 43.734. Mental health rehabilitation services. (a) The division will reimburse an enrolled provider for an intake assessment, a psychiatric assessment, or psychological testing and evaluation provided to a recipient 21 years of age or older, if the recipient is suspected to be an emotionally disturbed adult, a severely emotionally disturbed adult, or a chronically mentally ill adult. (b) If, at any time during the assessment, evaluation, or treatment of a recipient who is an emotionally disturbed adult, an enrolled provider of mental health services determines that the recipient may be a severely emotionally disturbed adult or chronically mentally ill adult, and that the recipient is in need of mental health rehabilitation services, the (1) provider shall refer the recipient to a community mental health clinic that provides mental health rehabilitation services in the community; and (2) community mental health clinic receiving a referral under this subsection shall conduct a functional assessment and develop an individualized treatment plan for the recipient in accordance with 7 AAC 43.728(c). (c) Subject to the requirements of this section, the division will reimburse a community mental health clinic for the following mental health rehabilitation services:


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(1) medication administration services, as described in 7 AAC 43.739, if the recipient is receiving at least one other mental health rehabilitation service; (2) a functional assessment, as described in 7 AAC 43.735; (3) case management, as described in 7 AAC 43.737; (4) individual skill development services, as described in 7 AAC 43.736; (5) group skill development services, as described in 7 AAC 43.474; (6) recipient support services, as described in 7 AAC 43.478; (7) the clinic services listed in 7 AAC 43.726(a). (d) The division will reimburse a provider for a mental health rehabilitation service if (1) the intake assessment indicates the recipient is a severely emotionally disturbed adult or a chronically mentally ill adult, and the recipient's functional assessment indicates deficits requiring remediation through one or more of the services listed in (c) of this section; and (2) a physician or a mental health professional clinician recommends the service, and a recommendation for that service is included in the recipient's individualized treatment plan and clinical record, as developed under 7 AAC 43.728. (e) The division will reimburse a provider for the services identified in (c) of this section if those services are provided as active treatment. (f) The division will reimburse a community mental health clinic for mental health rehabilitation services if the clinic ensures that the (1) need for mental health rehabilitation services is identified through an intake assessment conducted by a qualified mental health professional clinician and a functional assessment conducted by a mental health clinical associate; (2) mental health rehabilitation services are included in the recipient's individualized treatment plan that has been derived from the intake assessment and functional assessment; (3) mental health rehabilitation services are concurred in by

(A) an interdisciplinary team in accordance with 7 AAC 43.470, if the recipient is a severely emotionally disturbed child; or (B) a physician or mental health professional clinician, if the recipient is a severely emotionally disturbed adult or a chronically mentally ill adult;

(4) mental health rehabilitation services are provided in combination with other mental health, medical, or social services provided as active treatment that can be reasonably expected to increase the recipient's ability to function within the recipient's home, school, and community; and (5) staff providing rehabilitation services are mental health professional clinicians or mental health clinical associates, qualified by training or experience to implement mental health rehabilitation services as written in the individualized treatment plan. (g) The division will reimburse a community mental health clinic for the services listed in (c) of this section and 7 AAC 43.470(e) and provided to qualified recipients if the community mental health clinic


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(1) operates under a grant agreement with the division of mental health and developmental disabilities in the department in accordance with 7 AAC 71 and 7 AAC 78; and (2) provides services in accordance with a plan that

(A) ensures that all individuals who need mental health rehabilitation services offered through the community mental health clinic have equal access to the services, regardless of an individual's ability to pay; (B) describes and implements a permanent system of finding and offering services to the majority of individuals who are in need of mental health rehabilitation services in the community mental health clinic's catchment area as defined in the grant award by the division of mental health and developmental disabilities in the department; (C) assures that the community mental health clinic regularly communicates a description of the mental health rehabilitation services available through the community mental health clinic to all other local, state, and federal agencies that provide, or may provide, services to the individuals described in (A) of this paragraph; (D) is reviewed and updated annually by the community mental health clinic; and (E) is submitted and updated in accordance with (h) of this section.

(h) The plan of service required by (g)(2) of this section must be submitted to the division by the community mental health clinic according to the following schedule: (1) the plan must be submitted within 180 days after the date the grant was awarded; (2) an annual update of a plan for the succeeding fiscal year must be submitted no later than June 30 of each year. (Eff. 8/6/92, Register 123; am 12/31/92, Register 124; am 12/31/94, Register 132; readopt 8/7/96, Register 139; am 11/1/2000, Register 156 Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 Editor's note: Effective 8/7/96, Register 139, the Department of Health and Social Services readopted 7 AAC 43.734 in its entirety, without change, under AS 47.05 and AS 47.07. Executive Order No. 72 transferred certain rate-setting authority to the department. 7 AAC 43.735. Functional assessment. Subject to the requirements of 7 AAC 43.734, the division will reimburse a provider for a recipient's functional assessment that includes (1) the recipient's name, date of birth, address, and other identifying information; (2) the recipient's current living arrangement and status; (3) the name and address of the recipient's family or guardian, other identifying information, and an assessment of how the family functions; (4) a home-based functional assessment and current status; (5) a school or work functional assessment and current status; (6) a community-based functional assessment, cultural information, and current status;


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(7) a rehabilitation prognosis; and (8) rehabilitation service recommendations. (Eff. 12/31/94, Register 132; readopt 8/7/96, Register 139; am 11/1/2000, Register 156 Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 Editor's note: Effective 8/7/96, Register 139, the Department of Health and Social Services readopted 7 AAC 43.735 in its entirety, without change, under AS 47.05 and AS 47.07. Executive Order No. 72 transferred certain rate-setting authority to the department. 7 AAC 43.736. Individual skill development services. (a) Subject to the requirements of 7 AAC 43.734, the division will reimburse a provider for individual skill development services provided to a recipient in accordance with 7 AAC 43.470 or 7 AAC 43.734. (b) Individual skill development services may be provided within the home, workplace, or school, or any other appropriate community setting specified in the individualized treatment plan. (c) Individual skill development services must be provided exclusively to the identified recipient, and another individual may not receive services from the same service provider during the same session. (d) The division will reimburse a provider for individual skill development services at the rate specified for that service in 7 AAC 43.729 and subject to the service limitations in 7 AAC 43.727. (Eff. 12/31/94, Register 132; readopt 8/7/96, Register 139; am 11/1/2000, Register 156 Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 Editor's note: Effective 8/7/96, Register 139, the Department of Health and Social Services readopted 7 AAC 43.736 in its entirety, without change, under AS 47.05 and AS 47.07. Executive Order No. 72 transferred certain rate-setting authority to the department. 7 AAC 43.737. Case management. (a) Subject to the requirements of 7 AAC 43.734, the division will reimburse a provider for case management provided to a recipient in accordance with 7 AAC 43.470 or 7 AAC 43.734. (b) Case management may be provided within the home, workplace, or school, or any other appropriate community setting specified in the individualized treatment plan. (c) The division will reimburse a provider for case management at the rate specified for that service in 7 AAC 43.729 and subject to the service limitations in 7 AAC 43.727. (Eff. 12/31/94, Register 132; readopt 8/7/96, Register 139; am 11/1/2000, Register 156 Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 Editor's note: Effective 8/7/96, Register 139, the Department of Health and Social Services readopted 7 AAC 43.737 in its entirety, without change, under AS 47.05 and AS 47.07. Executive Order No. 72 transferred certain rate-setting authority to the department. 7 AAC 43.738. Crisis intervention. (a) Subject to the requirements of 7 AAC 43.726 and (e) of this section, the division will reimburse a provider for crisis intervention that is directly related to a recipient's acute episode of a mental, emotional or behavioral disorder.


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(b) Crisis intervention may be provided within the recipient's home, workplace, or school, or any other appropriate community setting. (c) The division will reimburse a provider for crisis intervention at the rate specified for that service in 7 AAC 43.729 and subject to the service limitations in 7 AAC 43.727. (d) Crisis intervention is limited to intake assessments, functional assessments, pharmacologic management, medication administration, case management, recipient support services, family skill development services, and crisis-oriented counseling. (e) Notwithstanding 7 AAC 43.728(e), the provider may document crisis intervention services on a brief contact form that the division has approved for describing the nature of the crisis, the services provided, and the effectiveness of the services in resolving the crisis. (Eff. 12/31/94, Register 132; am 3/13/96, Register 137; readopt 8/7/96, Register 139; am 11/1/2000, Register 156 Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 Editor's note: Effective 8/7/96, Register 139, the Department of Health and Social Services readopted 7 AAC 43.738 in its entirety, without change, under AS 47.05 and AS 47.07. Executive Order No. 72 transferred certain rate-setting authority to the department. 7 AAC 43.739. Medication administration services. (a) Subject to the requirements of 7 AAC 43.734, the division will reimburse a provider for medication administration services provided to a recipient in accordance with 7 AAC 43.470(e) or 7 AAC 43.734(c). (b) Medication administration services may be provided within the home or school, or any other appropriate community setting specified in the individualized treatment plan. (c) The division will reimburse a provider for medication administration services at the rate specified for that service in 7 AAC 43.729 and subject to the service limitations in 7 AAC 43.727. (Eff. 12/31/94, Register 132; readopt 8/7/96, Register 139; am 11/1/2000, Register 156 Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 Editor's note: Effective 8/7/96, Register 139, the Department of Health and Social Services readopted 7 AAC 43.739 in its entirety, without change, under AS 47.05 and AS 47.07. Executive Order No. 72 transferred certain rate-setting authority to the department.

Article 18 Substance Abuse Rehabilitative Services

Section 740. Substance abuse rehabilitative services. 741. Assessment and diagnosis services. 742. Outpatient services. 743. Intensive outpatient services. 744. Intermediate services. 745. Medical services. 746. Limitations and payments for services.


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7 AAC 43.740. Substance abuse rehabilitative services. (a) The division may reimburse enrolled providers for the following substance abuse rehabilitative services provided to a Medicaid recipient: (1) assessment and diagnosis services; (2) outpatient services, including

(A) individual, group, and family counseling, (B) care coordination, and (C) rehabilitation treatment services;

(3) intensive outpatient services; (4) intermediate services; and (5) medical services. (b) The division will enroll a provider of substance abuse rehabilitative services only if the provider is certified by the division of alcoholism and drug abuse in the department as: (1) a recipient of grant funds from the division of alcoholism and drug abuse; and (2) a valid certificate holder for an approved facility or program under 7 AAC 29.010 - 7 AAC 29.900. (c) The division will reimburse for a substance abuse rehabilitative service if the service is (1) identified as a treatment need in the intake assessment, the result of an evaluation, or the result of a reassessment during treatment; (2) provided by qualified program staff performing duties regularly within the scope of their authority, training, and job description; and (3) specified in the recipient's treatment plan which, based on the results of required assessments or evaluations, must

(A) be comprehensive and in writing; (B) specify

(i) the primary diagnosis and any relevant secondary diagnosis or diagnoses, (ii) a problem list, (iii) treatment objectives, (iv) the services to be provided, and (v) the frequency and expected duration of treatment;

(C) be signed and dated within 30 days of initial treatment by the person providing the service and authorized by a member of the supervisory staff in the substance abuse treatment center, the director of the substance abuse treatment center, or, in the case of contracted services, by a supervisor or the director of the contracting entity; (D) be reviewed by the director or a member of the supervisory staff of the substance abuse treatment center, or, in the case of contracted services, by a supervisor or the director of the contracting entity, within 90 days of the initiation of treatment and every six months thereafter; and (E) be included in the recipient's clinical record.


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(d) A progress note signed and dated by the person providing the service must be entered in the recipient's clinical record upon completion of each service episode. The progress note must describe the service provided and the duration of the service episode. (e) The department will reimburse for the services described in this section only if the documentation that is required to be in the recipient's record and treatment plan under the provisions of this section and 7 AAC 43.741(b) is complete. Subject to the other provisions of this subsection, a provider may satisfy the recordkeeping requirements of this section and 7 AAC 43.741(b) for recipient records through electronic records that meet the applicable requirements of 7 AAC 85. Notwithstanding the requirements of this section, a provider may be required to retain paper or paper-based copies of documents under other state or federal law for audit or other purposes. If a provider that is awarded a grant under 7 AAC 78 or 7 AAC 81 closes or ceases to exist as a service provider, the provider's records under that grant, including recipient records, are subject to the requirements of 7 AAC 78.255 or 7 AAC 81.185, as applicable. For purposes of this subsection, "paper-based copies" means documents stored on microfilm or microfiche, in tagged image file format (TIFF), portable document file (PDF) format, or in another format that allows for the efficient storage of documents. (f) The division will not reimburse for consultations outside of individual, group, or family counseling sessions, preparations of reports, recreation therapy, or vocational or employment counseling. (g) The division will reimburse an enrolled provider for covered services rendered by a public or private agency or company which contracts with the provider to furnish services, only if the contracting entity is approved by the division of alcoholism and drug abuse in the department to provide the services for which the enrolled provider is seeking Medicaid reimbursement. However, the division will neither enroll nor directly reimburse the contracting entity. (h) The division will reimburse an enrolled provider for the medical services specified in 7 AAC 43.745 which are provided by an entity which contracts with the provider to furnish medical services, only if the contracting entity is licensed as a medical professional in the state, is performing the service within the scope of appropriate licensure, and meets the applicable licensure or certification requirement specified for that service in 7 AAC 43.746. Except as specified in 7 AAC 43.746, the division will not directly reimburse the contracting entity for medical services provided under the contract, even if the contracting entity is separately enrolled as a Medicaid provider. (Eff. 2/23/94, Register 129; am 9/23/2004, Register 171 Authority: AS 18.23.100 AS 47.05.010 AS 47.07.030 Editor's note: Before Register 129, April 1994, the substance of 7 AAC 43.740 was generally contained in 7 AAC 43.928, which was adopted by emergency regulation and allowed to lapse on 12/3/92. The history note for 7 AAC 43.740 does not reflect the history note for 7 AAC 43.928. 7 AAC 43.741. Assessment and diagnosis services. (a) For the purposes of 7 AAC 43.740 - 7 AAC 43.746, assessment and diagnosis services include assessment and diagnostic tests, interviews, and status examinations administered to a recipient upon admission to an alcohol or drug abuse treatment program to determine a diagnosis and identify needed treatment services for inclusion in a recipient's treatment plan.


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Assessment and diagnosis services may include psychiatric assessments, psychological testing and evaluations, and psychosocial assessments, as defined in 7 AAC 43.1990. (b) The division will reimburse for assessment and diagnosis services only if those services are completed and documented in the recipient's clinical record by a substance abuse counselor, social worker, or other qualified professional specified in 7 AAC 43.740 within two weeks of the recipient's admission to an approved alcohol or drug abuse treatment program. The assessment or diagnosis report must be included in the recipient's clinical record and must be updated as new information becomes available. (Eff. 2/23/94, Register 129 Authority: AS 47.05.010 AS 47.07.030 Editor's note: Before Register 129, April 1994, the substance of 7 AAC 43.741 was generally contained in 7 AAC 43.929, which was adopted by emergency regulation and allowed to lapse on 12/3/92. The history note for 7 AAC 43.741 does not reflect the history note for 7 AAC 43.929. 7 AAC 43.742. Outpatient services. For the purposes of 7 AAC 43.740 - 7 AAC 43.746, outpatient services include one or more of the following services provided to a recipient who is emotionally stable enough to function in that recipient's own environment, as certified in the recipient's treatment plan: (1) individual counseling; (2) group counseling; (3) family counseling; (4) care coordination; and (5) rehabilitation treatment services. (Eff. 2/23/94, Register 129 Authority: AS 47.05.010 AS 47.07.030 Editor's note: Before Register 129, April 1994, the substance of 7 AAC 43.742 was generally contained in 7 AAC 43.930, which was adopted by emergency regulation and allowed to lapse on 12/3/92. The history note for 7 AAC 43.742 does not reflect the history note for 7 AAC 43.930. 7 AAC 43.743. Intensive outpatient services. For the purposes of 7 AAC 43.740 - 7 AAC 43.746, intensive outpatient services include one or more of the services listed in 7 AAC 43.742 provided to a recipient whose treatment plan requires that those services be delivered in a structured program, but who is emotionally stable enough to function in that recipient's own environment as certified in the recipient's treatment plan. (Eff. 2/23/94, Register 129 Authority: AS 47.05.010 AS 47.07.030 Editor's note: Before Register 129, April 1994, the substance of 7 AAC 43.743 was generally contained in 7 AAC 43.931, which was adopted by emergency regulation and allowed to lapse on 12/3/92. The history note for 7 AAC 43.743 does not reflect the history note for 7 AAC 43.931. 7 AAC 43.744. Intermediate services. For the purposes of 7 AAC 43.740 - 7 AAC 43.746, intermediate services include one or more of the services listed in 7 AAC 43.742 provided to a recipient whose treatment plan requires that those services by delivered in a structured residential program at a level of care exceeding that available in an outpatient treatment program. (Eff. 2/23/94, Register 129 Authority: AS 47.04.010 AS 47.07.030


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Editor's note: Before Register 129, April 1994, the substance of 7 AAC 43.744 was generally contained in 7 AAC 43.934, which was adopted by emergency regulation and allowed to lapse on 12/3/92. The history note for 7 AAC 43.744 does not reflect the history note for 7 AAC 43.934. 7 AAC 43.745. Medical services. Medical services must be furnished at the provider's routine place of business, unless otherwise specified in this section or in 7 AAC 43.746. The division will separately reimburse for the following medical services only if they are specified as medically necessary in a recipient's intake assessment or in a recipient's treatment plan: (1) medical evaluation upon admission for treatment for a recipient seeking methadone treatment, including consultation and referral, verification of addiction, and establishing methadone dosage; (2) an intake physical for a non-methadone recipient; (3) a periodic treatment plan review for a methadone recipient; (4) medication management, as defined in 7 AAC 43.1990; (5) the dispensing of methadone or antabuse; (6) a urinalysis; and (7) detoxification, which includes the immediate physiological stabilization, diagnosis, and treatment of a recipient who is intoxicated, incapacitated, or experiencing withdrawal from the ingestion of drugs. (Eff. 2/23/94, Register 129 Authority: AS 47.05.010 AS 47.07.030 Editor's note: Before Register 129, April 1994, the substance of 7 AAC 43.745 was contained in 7 AAC 43.936, which was adopted by emergency regulation and allowed to lapse on 12/3/92. The history note for 7 AAC 43.745 does not reflect the history note for 7 AAC 43.936. 7 AAC 43.746. Limitations and payments for services. (a) The division will reimburse for substance abuse rehabilitative services with the following limitations: (1) assessment and diagnosis services are limited to two in a consecutive 12-month period and to one group of necessary tests, evaluations, interviews, or examinations for each admission to a program, at the lesser of the rate routinely charged to the general public or $50 per service; (2) the total combination of individual, group, and family counseling provided as outpatient services is limited to no more than 40 hours in any consecutive 12-month period and reimbursement is subject to the following limitations:

(A) outpatient individual counseling is limited to the lesser of the rate routinely charged to the general public or $50 per hour; (B) outpatient group counseling is limited to the lesser of the rate routinely charged to the general public or $20 per hour for each Medicaid recipient present; (C) outpatient family counseling, which must be attended by at least one Medicaid recipient who is admitted to an approved substance abuse treatment program for at least half of each session, is limited to the lesser of the rate routinely charged to the general public or $45 per hour;

(3) outpatient care coordination services, for which each reimbursable contact must be at least twenty minutes in length, and is limited to a maximum of eight


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hours in any consecutive six-month period, at the lesser of the rate routinely charged to the general public or $30 per hour; (4) outpatient rehabilitation treatment services is limited to ten hours per week and to a maximum of 40 hours in any consecutive 12-month period, at the lesser of the rate routinely charged to the general public or $40 per hour; (5) intensive outpatient services must be provided for at least three days or evenings per week and for at least eight hours per week, but are limited to a maximum of 12 hours per week, and may not exceed eight consecutive weeks in any consecutive 12-month period, at the lesser of the rate routinely charged to the general public or $45 per hour; in any day in which intensive outpatient services are provided, the division will not separately reimburse for individual, group, and family counseling, care coordination, or rehabilitation treatment services provided to the recipient as outpatient services; (6) intermediate services are limited to 20 hours per week, not to exceed eight weeks in any consecutive 12-month period, at the lesser of the rate routinely charged to the general public or $50 per hour; in any day in which intermediate services are provided, the division will not separately reimburse for individual, group, and family counseling, care coordination, or rehabilitation treatment services provided to the recipient as outpatient services; (7) a medical evaluation upon admission for treatment for a recipient seeking methadone treatment, which must be conducted by a physician, at the lesser of the amount routinely charged to the general public or $300 per evaluation; (8) an intake physical for a non-methadone recipient, which must be conducted by a physician, a physician's assistant, or an advanced nurse practitioner, at the lesser of the rate routinely charged to the general public or $150 per physical; (9) a treatment plan review for a methadone recipient, which must be conducted by a physician, at the lesser of the rate routinely charged to the general public or $30 per review; (10) medication management, as defined in 7 AAC 43.1990, at the lesser of the rate routinely charged to the general public or $35 per visit; (11) dispensing of methadone or antabuse, which must be conducted by a physician, an advanced nurse practitioner, a physician's assistant, a registered nurse, or a licensed practical nurse, at the lesser of the rate routinely charged to the general public or $10 per visit; (12) urinalysis, which must be performed by a laboratory certified under 42 C.F.R. 493, as amended November 1, 1993, at the rate determined under 7 AAC 145.460; and (13) detoxification is limited to 12 admissions in any consecutive 12-month period, at the lesser of the rate routinely charged to the general public or $150 for each consecutive 24-hour period; the division will not pro-rate or otherwise reimburse for any service period less than 24 consecutive hours. (b) Except as provided in (c) of this section, a provider of substance abuse rehabilitative services may exceed the service limits of this section for a recipient who is 21 years of age or older only upon written approval by the division of alcoholism and drug abuse in the department of a written request by the provider. (c) A provider of substance abuse rehabilitative services may exceed the service limits of this section for a recipient who is under 21 years of age or for a recipient of any


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age who is pregnant only if the provider enters a statement containing medical justification into the recipient's clinical record. (Eff. 2/23/94, Register 129; am 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 Editor's note: Before Register 129, April 1994, part of the substance of 7 AAC 43.746 was contained in 7 AAC 43.928 - 7 AAC 43.937 which were adopted by emergency regulation and allowed to lapse on 12/3/92. The history note for 7 AAC 43.746 does not reflect the history note for those sections.

Article 34 Section 1990. Definitions 7 AAC 43.1990. Definitions. In this chapter, unless the context requires otherwise, (1) "active treatment" means the planning, delivery, and monitoring of a dynamic set of interrelated, effective, culturally appropriate, individualized, mental health rehabilitation and related support services that

(A) are designed to meet the mental health service needs of a recipient; (B) use a specific and clear intervention strategy targeting behaviors identified in an intake assessment and individualized treatment plan; (C) are designed to improve functioning, reduce or eliminate negative symptoms, demonstrate ongoing measurable progress, and enhance the quality of a recipient’s life; (D) are provided by qualified staff to a recipient who is an active participant in the treatment process; and (E) have a goal more specific than simply the avoidance of institutional care;

(2) "case management" means a mental health rehabilitation service described in 7 AAC 43.737 provided by enrolled providers to recipients under 7 AAC 43.470 or 7 AAC 43.734(c) that assists the recipient and the recipient’s family in the access and coordination of needed medical, psychiatric, mental health, educational, vocational, social-supports, or community-based services, related assessments, and post-discharge follow-up activities; (3) "chronically mentally ill adult" means an individual 21 years of age or older

(A) who has been diagnosed as having a schizophrenic, major affective, or paranoid disorder, or other severe mental disorder with a documented history of persistent psychotic symptoms not caused by substance abuse; and (B) whose functioning is impaired in at least two of the following three ways:

(i) inability to function independently as a worker or a student, or in the home; (ii) inability to engage independently in personal care or community living activities;


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(iii) inability to exhibit appropriate social behavior, resulting in intervention by the mental health system or judicial system;

(4) "community mental health clinic" has the meaning given in 7 AAC 160.990; (5) "crisis intervention" has the meaning given in 7 AAC 160.990; (6) "day treatment services" means a combined program of therapeutic and academic services coordinating mental health services and resources with school district services and resources to assist a recipient who is a severely emotionally disturbed child to improve the recipient’s daily functioning within, or make a transition to, the community-based school environment; day treatment services may include a specific mental health component that provides counseling, monitoring, and support necessary to keep the child within the community-based school environment; (7) "department" means the Department of Health and Social Services; (8) "director" means the director of the division; (9) "direct supervision" means that, in a mental health physician clinic, a psychiatrist is on the premises to deliver medical services at least 60 percent of the time the clinic is open for providing medical services, and for an additional time needed to meet all of the following medical responsibilities:

(A) sees each recipient at least once, prescribes the care to be provided, approves the individualized treatment plan in writing, and at least every six months reviews each case to determine the need for continued care; (B) provides direct clinical consultation and supervision to clinic staff; (C) assumes professional responsibility for the services provided and assures that the services are medically appropriate;

(10) "division" means the division within the department with responsibility over behavioral health; (11) "emotionally disturbed adult" means an individual 21 years of age or older who is diagnosed as having a mental disorder with nonpersistent nonpsychotic symptoms and whose role functioning is not significantly impaired, or is impaired in no more than one of the following three ways; for purposes of this paragraph, "mental disorder" does not include mental retardation or a substance abuse disorder:

(A) inability to function independently as a worker, as a student, or in the home; (B) inability to engage independently in personal care or community living activities; (C) inability to exhibit appropriate social behavior, resulting in intervention by the mental health system or judicial system;

(12) "emotionally disturbed child" means an individual under 21 years of age who

(A) has a mental, emotional, or behavioral disorder that (i) is identified during an intake assessment; (ii) is not the result of intellectual, physical, or sensory deficits; and (iii) disrupts the individual’s ability to function within the individual’s home, school, or other educational setting; within the


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individual’s community; or within the individual’s family or other significant interpersonal relationships; and

(B) requires mental health services to meet the identified needs of the individual and the individual’s family;

(13) "family counseling" means the provision of a counseling session conducted by one or more counselors for the recipient and members of the recipient’s immediate or extended family or social network; in this paragraph, "extended family" means a parent, spouse, child, grandparent, or grandchild of the recipient; (14) "family psychotherapy" has the meaning given in 7 AAC 160.990; (15) "family skill development services" means face-to-face therapeutic skill instruction, skill practice, and skill monitoring that is

(A) provided to a single recipient who is a severely emotionally disturbed child and to the family of that recipient; (B) provided in the family home, or in a clinic or other location; (C) included in the recipient’s individualized treatment plan; and (D) designed to help the family and the recipient learn more effective ways to impact the recipient’s symptoms and inappropriate behavior;

(16) "functional assessment" means a systematic evaluation of a recipient to assess that recipient’s functioning level in the areas of living skills, learning, education, work, interpersonal skills, and other life skills necessary for independent living, in order to develop an individualized written treatment plan; (17) "functional impairment" means a disorder that substantially interferes with or prevents a recipient from achieving or maintaining one or more developmentally appropriate social, behavioral, cognitive, communicative, or adaptive skills; "functional impairment" includes disorders of episodic, recurrent, or continuous duration; "functional impairment" does not include temporary, expected responses to stressful events in the recipient's environment; (18) "general direction" means that, in a community mental health clinic, a physician

(A) is on the premises to deliver consultative and treatment services at least one day per month unless the department determines that travel conditions have prevented transportation access, and at other times is readily available by telephone for program and case consultation; (B) provides general program and clinical consultation to clinic staff to ensure that services are medically necessary, as determined in accordance with 7 AAC 43.486; and (C) provides pharmacologic management to recipients on psychotropic medications, and provides treatment or consultative services to other recipients upon referral;

(19) "group counseling" means a counseling session conducted by one or more counselors for two or more unrelated recipients who are not members of the same household; (20) "group psychotherapy" means a form of psychotherapy in which two or more individuals participate together in the presence of one or more psychotherapists; (21) "group skill development services" has the meaning given in 7 AAC 160.990;


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(22) "hospital" has the meaning given in 7 AAC 160.990; (23) "individual counseling" means a counseling session conducted by one substance abuse counselor for one recipient; (24) "individual skill development services" has the meaning given in 7 AAC 160.990; (25) "individualized treatment plan" means a written document that

(A) is developed in cooperation with the recipient and other members of any interdisciplinary team organized under 7 AAC 43.470; and (B) includes, at minimum, the components identified in 7 AAC 43.728;

(26) "intake assessment" has the meaning given in 7 AAC 160.990; (27) "interdisciplinary team" means a group of individuals listed in 7 AAC 43.470(k) who are directly involved in the mental health treatment of a severely emotionally disturbed child, and who develop, implement, monitor, and evaluate an individualized treatment plan designed to improve the quality of the recipient's life; (28) "Medicaid" has the meaning given in 7 AAC 160.990; (29) "medication administration services" means the administration, by appropriately licensed medical personnel, of injectable or oral medications to a recipient, and documentation of medication compliance, assessment and documentation of side effects, and evaluation and documentation regarding the effectiveness of the medication; (30) "medication management" has the meaning given in this section for "pharmacologic management"; (31) "mental health clinical associate" means an individual who

(A) may have less than a master’s degree in psychology, social work, counseling, or a related field with specialization or experience in working with chronically mentally ill adults or severely emotionally disturbed children; (B) whose responsibilities may include psychosocial evaluation, individual skill development services, recipient support services, group skill development services, family skill development services, or day treatment services; and (C) who works within the scope of the individual’s training and experience and under the direction of a mental health professional clinician, physician, or psychiatrist in a community mental health clinic;

(32) "mental health physician clinic" means a clinic, operated by one or more psychiatrists, that exclusively or primarily provides mental health services furnished by a psychiatrist or by one or more

(A) psychologists, psychological associates, clinical social workers, or psychiatric mental health clinical nurse specialists who are licensed to practice in the jurisdiction in which the service is provided and have any additional required certification; (B) marital and family therapists who are licensed under AS 08.63 or in a jurisdiction where services are provided, with requirements substantially similar to the requirements of AS 08.63, and who work in their field of expertise under the direct supervision of a psychiatrist; or (C) professional counselors who are licensed under AS 08.29 or in a jurisdiction where services are provided, with requirements substantially similar


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to the requirements of AS 08.29, and who work in their field of expertise under the direct supervision of a psychiatrist;

(33) "mental health professional clinician" means (A) an individual with a master’s degree or more advanced degree in psychology, social work, counseling, child guidance, or nursing, with specialization or experience in mental health who, if employed by a mental health physician clinic, is licensed to practice in the jurisdiction in which the service is provided; (B) a marital and family therapist who is licensed under AS 08.63 or in a jurisdiction where services are provided, with requirements substantially similar to the requirements of AS 08.63, and who works in the individual’s field of expertise; or (C) a professional counselor who is licensed under AS 08.29 or in a jurisdiction where services are provided, with requirements substantially similar to the requirements of AS 08.29, and who works in the individual’s field of expertise;

(34) "pharmacologic management" means assessing a recipient's need for pharmacotherapy and prescribing appropriate medications to meet the recipient's need by a physician, a physician's assistant, or an advanced nurse practitioner with prescriptive authority, and monitoring the recipient's response to medication by appropriately licensed medical professionals, including documentation of medication compliance, assessment and documentation of side effects, and evaluation and documentation regarding the effectiveness of the medication; (35) "provider" has the meaning given in 7 AAC 160.990; (36) "psychiatric assessment" means a systematic evaluation of a recipient to determine symptomatology, establish a diagnosis, and prescribe needed treatment; (37) "psychiatric facility" has the meaning given in 7 AAC 160.990; (38) "psychiatrist" means a physician licensed to practice medicine in the state in which services are provided, and who has completed a fully qualified residency in psychiatry; (39) "psychological associate" means an individual licensed in the state in which services are provided, who renders specific mental health services in association with a licensed psychologist within the scope of practice identified in 12 AAC 60.185; (40) "psychological testing and evaluation" means the administration of standardized psychological tests and interpretation of findings by a psychologist, a psychological associate, or another mental health professional clinician with appropriate education and training, for the purpose of providing assistance in the psychiatric diagnosis of mental and emotional disorders or the assessment of functional capabilities; (41) "psychologist" means an individual who is licensed to practice psychology in the jurisdiction in which services are provided; (42) "psychosocial assessment" has the meaning given in this section for "functional assessment"; (43) "recipient" means an individual for whom payment is made under the Medicaid program; (44) "recipient's representative" has the meaning given in 7 AAC 160.990;


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(45) "recipient support services" means face-to-face counseling to provide structure, supervision, and monitoring necessary to maintain and protect a severely emotionally disturbed child or adult, or a chronically mentally ill adult recipient within the recipient’s home, workplace, school, and community and prevent harm to the recipient or to others; "recipient support services" does not include those daily supervisory activities that a parent or foster parent would normally carry out to assure protection, emotional support, and care of a child who is not a severely emotionally disturbed child, or those daily supervisory activities normally provided by or within an assisted living facility, congregate housing facility, or group home for care of an adult who is not a severely emotionally disturbed adult or is not a chronically mentally ill adult; (46) "rehabilitation treatment services" means a program of treatment services that are provided, either individually or in a group setting, to a recipient of substance abuse treatment, with the objective of improving the functioning level of the recipient through supporting or strengthening the behavioral, emotional, or intellectual skills necessary to live, learn, or work in the recipient’s environment; (47) "severely emotionally disturbed adult" means an individual 21 years of age or older who is diagnosed as having a severe personality disorder, organic disorder, or other mental disorder with persistent nonpsychotic symptoms and who, as the result of the disorder, has impairment in role functioning in at least two of the following three ways:

(A) inability to function independently as worker or a student, or in the home; (B) inability to engage independently in personal care or community living activities; (C) inability to exhibit appropriate social behavior, resulting in intervention by the mental health system or judicial system;

(48) "severely emotionally disturbed child" means an individual under 21 years of age who meets the requirements of 7 AAC 43.471; (49) "treatment plan review" means the process of reviewing and documenting a recipient’s response to treatment and progress toward the goals outlined in the treatment plan, on a scheduled quarterly or semi-annual basis, documented as required under 7 AAC 43.728, and with active participation by the recipient, the recipient’s family, the recipient’s treatment providers, or other individuals involved in recipient’s treatment. (Eff. 12/31/92, Register 124; am 5/5/93, Register 126; am 6/5/93, Register 126; am 12/19/93, Register 128; am 2/23/94, Register 129; am 12/24/94, Register 132; am 8/13/95, Register 135; am 1/1/96, Register 136; readopt 8/7/96, Register 139; am 2/1/97, Register 141; am 11/29/97, Register 144; am 6/26/98, Register 146; am 5/5/99, Register 150; am 11/1/2000, Register 156; am 7/11/2002, Register 163; am 3/26/2003, Register 165; am 5/15/2004, Register 170; am 8/19/2004, Register 171; am 4/28/2005, Register 174; am 12/30/2006, Register 180; am 5/23/2008; Register 186; am 2/1/2010, Register 193) Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040 Editor's note: This section is substantially similar to the emergency regulation 7 AAC 43.730 that took effect August 6, 1992, Register 123 (October 1992). That section, however, was not made permanent and the substantive provisions of it were moved to this section. As of Register 126 (July 1993),


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the contents of 7 AAC 43.990 were combined with former 7 AAC 43.090. The history line of former 7 AAC 43.090 was not incorporated into the 7 AAC 43.990 history line. Effective March 26, 1993, amendments to the definition of "psychiatric facility" and a new definition of "residential psychiatric treatment center" were adopted as emergency amendments to former 7 AAC 43.090. Those regulations were amended and made permanent on 6/5/93, as shown in 7 AAC 43.990 as of Register 126 (July 1993). As of Register 126 (July 1993), definitions of "inpatient psychiatric hospital facility," "inpatient psychiatric services," "inpatient interdisciplinary team," and "professional review organization," originally adopted in 7 AAC 43.580 as emergency regulations on January 1, 1993 and amended March 26, 1993, were moved to 7 AAC 43.990 and renumbered. As of Register 132 (January 1995), the definitions in this section have been reorganized to put them in alphabetical order, regardless of when each of them was adopted. Effective 8/7/96, Register 139, the Department of Health and Social Services readopted 7 AAC 43.1990 in its entirety, without change, under AS 47.05 and AS 47.07. Executive Order No. 72 transferred certain rate-setting authority to the department. As of Register 184 (January 2008), the regulations attorney made a technical revision under AS 44.62.125(b)(6), to 7 AAC 43.1990, renumbering paragraphs to close a break in the numerical sequence between 7 AAC 43.1990(97) and (99). As of Register 193 (April 2010), the definitions in 7 AAC 43.1990 have been reorganized to put them in alphabetical order, regardless of when each of them was adopted. For definitions formerly in 7 AAC 43.1990 and relating to elements of the Medicaid program other than those addressed in 7 AAC 43.470 - 7 AAC 43.488 or 7 AAC 43.725 - 7 AAC 43.746, see 7 AAC 105 - 7 AAC 160.

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