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7 AAC 145.520. Home and community-based waiver services 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,

(1) the department will pay a unit of service at the lesser of the

(A) amount charged by the provider to the public; or

(B) rates established in the department's Chart of Personal Care Services, Community First Choice Services and Waiver Service Rates, adopted by reference in 7 AAC 160.900;

(2) the rate of payment for care coordination services provided under 7 AAC 130.240(b) (1) and (2) will be reestablished at least every four years using a modeled rate methodology that accounts for salaries, fringe benefits, administrative/general, and caseload size; and

(3) each July 1 that the rates of payment for care coordination services in the Chart of Personal Care Services, Community First Choice Services and Waiver Services Rates are not reestablished under (2) of this section, the rates will be adjusted as provided in 7 AAC 145.525(b) .

(c) For specialized medical equipment and supplies provided under 7 AAC 130.305, the department will pay at the lesser of the

(1) amount charged by the provider in accordance with 7 AAC 145.020; or

(2) maximum allowable amount specified for that item in the Specialized Medical Equipment Fee Schedule, adopted by reference in 7 AAC 160.900.

(d) For specialized private duty nursing services provided under 7 AAC 130.285, the department will pay a unit of service at the lesser of the

(1) amount charged by the provider in accordance with 7 AAC 145.020; or

(2) rate described in 7 AAC 145.250.

(e) For environmental modification services provided under 7 AAC 130.300, the department will pay at 100 percent of billed charges to a home and community-based waiver services provider that oversees the purchase and installation of an environmental modification for a recipient. In addition, the department will pay the provider an administrative fee of two percent of the billed charges or $100, whichever is greater, if the provider is

(1) certified under 7 AAC 130.220(a) (1)(K); and

(2) an organized health care delivery system under 42 C.F.R. Part 447.

(f) For chore services provided under 7 AAC 130.245, adult day services provided under 7 AAC 130.250, residential supported-living services provided under 7 AAC 130.255, 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 meal services provided under 7 AAC 130.295, the department will pay a unit of service at the lesser of

(1) the amount charged by the provider in accordance with 7 AAC 145.020; or

(2) rates established in the department's Chart of Personal Care Services, Community First Choice Services and Waiver Services Rates, adopted by reference in 7 AAC 160.900.

(g) For the types of service listed in (f) of this section other than intensive active treatment services provided under 7 AAC 130.275, if the provider's average per-unit allowed amount for the type of service, for claims with dates of service after June 30, 2009 and before October 1, 2009, and processed before February 3, 20l0, is higher than the rate established under (f) of this section, the recipient care rate before the effective date of newly rebased rates using the methodology established in the department's Personal Care Attendant and Waiver Rate-Setting Methodology, adopted by reference in 7 AAC 160.900, is the average per-unit allowed amount for the period after June 30, 2009 and before October 1, 2009.

(h) A qualified recipient receiving residential supported-living services under 7 AAC 130.255 that are assigned procedure code T2031 in the Healthcare Common Procedure Coding System (HCPCS), adopted by reference in 7 AAC 160.900, or group-home habilitation services under 7 AAC 130.265 that are assigned procedure code T2016 in the Healthcare Common Procedure Coding System, is eligible for, in addition to the qualified recipient's daily rate provided under (f) and (g) of this section, an acuity add-on rate at the daily rate established in the Chart of Personal Care Services, Community First Choice Services and Waiver Services Rates, adopted by reference in 7 AAC 160.900. For purposes of this subsection, a qualified recipient is a recipient for whom the department has given prior authorization under 7 AAC 130.267 for additional services.

(i) If a recipient has been determined eligible for Medicaid coverage under 7 AAC 100.002(d) (8), the recipient's income, exclusive of the personal needs allowance and other deductions described in 7 AAC 100.550 - 7 AAC 100.579 is a prior resource for home and community-based waiver services. Once the department has determined the recipient's monthly liability under 7 AAC 100.550 - 7 AAC 100.579, 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.

History: Eff. 2/1/2010, Register 193; am 3/1/2011, Register 197; am 4/1/2012, Register 201; am 7/1/2013, Register 206; am 1/1/2014, Register 208; am 7/1/2015, Register 214; am 8/18/2015, Register 215; am 10/1/2017, Register 223; am 3/1/2018, Register 225; am 10/1/2018, Register 227

Authority: AS 47.05.010

AS 47.07.030

AS 47.07.040

7 AAC 145.520. Home and community-based waiver services 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,

(1) the department will pay a unit of service at the lesser of the

(A) amount charged by the provider to the public; or

(B) rates established in the department's Chart of Waiver Services Rates, adopted by reference in 7 AAC 160.900;

(2) the rate of payment for care coordination services provided under 7 AAC 130.240(b) (1) and (2) will be reestablished at least every four years using a modeled rate methodology that accounts for salaries, fringe benefits, administrative/general, and caseload size; and

(3) each July 1, except July 1, 2019, that the rates of payment for care coordination services in the Chart of Waiver Services Rates are not reestablished under (2) of this section, the rates will be adjusted as provided in 7 AAC 145.525(b) .

(c) For specialized medical equipment and supplies provided under 7 AAC 130.305, the department will pay at the lesser of the

(1) amount charged by the provider in accordance with 7 AAC 145.020; or

(2) maximum allowable amount specified for that item in the Specialized Medical Equipment Fee Schedule, adopted by reference in 7 AAC 160.900.

(d) For specialized private duty nursing services provided under 7 AAC 130.285, the department will pay a unit of service at the lesser of the

(1) amount charged by the provider in accordance with 7 AAC 145.020; or

(2) rate described in 7 AAC 145.250.

(e) For environmental modification services provided under 7 AAC 130.300, the department will pay at 100 percent of billed charges to a home and community-based waiver services provider that oversees the purchase and installation of an environmental modification for a recipient. In addition, the department will pay the provider an administrative fee of two percent of the billed charges or $100, whichever is greater, if the provider is

(1) certified under 7 AAC 130.220(a) (1)(K); and

(2) an organized health care delivery system under 42 C.F.R. Part 447.

(f) For chore services provided under 7 AAC 130.245, adult day services provided under 7 AAC 130.250, residential supported-living services provided under 7 AAC 130.255, 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 meal services provided under 7 AAC 130.295, the department will pay a unit of service at the lesser of

(1) the amount charged by the provider in accordance with 7 AAC 145.020; or

(2) rates established in the department's Chart of Waiver Services Rates, adopted by reference in 7 AAC 160.900.

(g) For the types of service listed in (f) of this section other than intensive active treatment services provided under 7 AAC 130.275, if the provider's average per-unit allowed amount for the type of service, for claims with dates of service after June 30, 2009 and before October 1, 2009, and processed before February 3, 20l0, is higher than the rate established under (f) of this section, the recipient care rate before the effective date of newly rebased rates using the methodology established in the department's Personal Care Attendant and Waiver Rate-Setting Methodology, adopted by reference in 7 AAC 160.900, is the average per-unit allowed amount for the period after June 30, 2009 and before October 1, 2009.

(h) A qualified recipient receiving residential supported-living services under 7 AAC 130.255 that are assigned procedure code T2031 in the Healthcare Common Procedure Coding System (HCPCS), adopted by reference in 7 AAC 160.900, or group-home habilitation services under 7 AAC 130.265 that are assigned procedure code T2016 in the Healthcare Common Procedure Coding System, is eligible for, in addition to the qualified recipient's daily rate provided under (f) and (g) of this section, an acuity add-on rate at the daily rate established in the Chart of Waiver Services Rates, adopted by reference in 7 AAC 160.900. For purposes of this subsection, a qualified recipient is a recipient for whom the department has given prior authorization under 7 AAC 130.267 for additional services.

(i) If a recipient has been determined eligible for Medicaid coverage under 7 AAC 100.002(d) (8), the recipient's income, exclusive of the personal needs allowance and other deductions described in 7 AAC 100.550 - 7 AAC 100.579 is a prior resource for home and community-based waiver services. Once the department has determined the recipient's monthly liability under 7 AAC 100.550 - 7 AAC 100.579, 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.

History: Eff. 2/1/2010, Register 193; am 3/1/2011, Register 197; am 4/1/2012, Register 201; am 7/1/2013, Register 206; am 1/1/2014, Register 208; am 7/1/2015, Register 214; am 8/18/2015, Register 215; am 10/1/2017, Register 223; am 3/1/2018, Register 225; am 10/1/2018, Register 227; am 7/1/2019, Register 231

Expires 10/28/2019 unless made "permanent" by the adopting agency.

Authority: AS 47.05.010

AS 47.07.030

AS 47.07.040

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