Home- and Community-Based Services for the Elderly and Disabled (Rule No. 560-X-36-.01)
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Governs Alabama Medicaid's Home- and Community-Based Services (HCBS) waiver for elderly and disabled individuals at risk of nursing facility placement, defining eligible populations, covered services, provider qualifications, documentation, and limits.
No material clinical or coverage changes in this revision.
Coverage criteria and service rules
General Waiver Eligibility and Service Coverage
Covered when ALL of the following are met:
From Authority/Purpose and Eligibility sections
Plan of Care and Service Authorization requirement
HCBS settings rule and provider qualification statements
Service-specific Coverage Criteria
Service-specific coverage rules (examples):
Respite care restrictions
Meal service definitions and limits
Home modification coverage and exclusions
Medical supplies billing limits
AT/DME limits and requirements
Skilled Nursing Services
Skilled Nursing Services covered when ALL of the following are met:
Skilled nursing scope, supervision, and documentation requirements
Assistive Technology/DME and Skilled Nursing Coverage Criteria
Covered when ALL of the following are met:
AT/DME documentation, prior authorization, and limits
Skilled nursing duplication and documentation rules
Pest Control Services
Pest Control Coverage:
Pest control service limits and exclusions
Supervisory Visits
Supervisory visit coverage and billing rules:
Billing increment, frequency, documentation, and reimbursement rules
Services may not be provided in settings that are excluded under the HCBS settings requirements. Excluded settings include nursing facilities, institutions for mental disease, intermediate care facilities for individuals with intellectual disabilities, and hospitals. The waiver also prohibits services in presumed-institutional settings—facilities that provide inpatient treatment, are located on or immediately adjacent to public institutions, or that have the effect of isolating waiver recipients from the broader community. All waiver services must be identified on the recipient's Plan of Care and Service Authorization Form; services not listed on that plan are not reimbursable and payments will be recovered.
Home Modification Services cover physical adaptations necessary to ensure the recipient's health, welfare, and safety or to enable greater independence and avoid institutionalization (examples: ramps, grab-bars, doorway widening). Excluded from coverage are adaptations or improvements that are not of direct medical or remedial benefit, any changes that add to the total square footage of the home, construction that affects the structural integrity of the home, and changes to existing electrical components. Modifications must be performed by a licensed contractor and comply with state/local building codes and ADAAG; prior authorization and the lifetime limit provisions apply.
Payment will not be made for Personal Care, Respite, Companion, or Homemaker Services when those services are furnished by a member of the recipient's family. Personal Care attendants must be employed by a certified Home Health Agency or another Alabama Medicaid–approved agency and supervised by a licensed nurse; Companion Services and Respite Services similarly require documentation on the Plan of Care and Service Authorization Form and are not payable if provided by a family member. Companion Services are available only to clients living alone and must not exceed four hours daily.
Certain costs and items are specifically unallowable under the waiver. Examples include expenses that are the financial responsibility of other programs or that are outside the scope of waiver services (for example, prescription drugs or services covered under the State Plan), costs associated with non‑covered therapies or services, and administrative or legal costs not approved by the Agency. All waiver services must be documented on the Plan of Care and Service Authorization Form; services not documented will not be paid and payments will be recovered.
Pest Control Services exclude certain ancillary costs associated with treatment. Coverage is limited to chemical eradication by a State‑licensed and certified pest control professional and includes assessment, pesticide application, and follow up. However, the program does not cover lodging during the chemical eradication process, any preparatory housework associated with the treatment, or the replacement of household items. Pest control is limited to one series of treatments per lifetime unless additional treatment is necessary to preserve the participant's ability to live in the community and is approved by the State.
Providers shall not use or disclose information concerning an eligible recipient except to duly authorized federal or state representatives, or with the recipient's written consent (or that of the recipient's attorney or guardian), or upon subpoena from a court of appropriate jurisdiction. Unauthorized disclosure of recipient information may violate confidentiality rules and subject the provider to enforcement action.
Waiver services are not entitlements; provision of services is based on the individual recipient's assessed needs and documented on the Plan of Care and Service Authorization Form. The E/D waiver is not intended to provide 24‑hour in‑home care; if continuous around‑the‑clock care becomes necessary to protect a participant's health and safety, the appropriateness of waiver services must be reassessed and alternative arrangements considered.
Assistive Technology and Durable Medical Equipment must be medically necessary, ordered by a physician with the prescription maintained in the case file, and supplied by providers meeting waiver qualifications. Items that are not medically necessary—that is, not directed toward the maintenance, improvement, or protection of health or toward diagnosis or treatment—are not covered. Documentation in the provider's medical record must substantiate medical necessity, and AT/DME requires prior authorization; annual and lifetime dollar limits apply.
Billing and code rules
| HCPC | Each covered service is identified on a claim by a HCPC code; respite care will have one code for skilled and another for unskilled. Home delivered meals will have one code and two modifiers; frozen meals and shelf stable meals billed with a modifier; breakfast meals billed without a modifier. |
Provider requirements, authorizations, and audit obligations
Prior authorization required; home modification and AT/DME limits
Home Modification Services and Assistive Technology/Durable Medical Equipment (AT/DME) require prior authorization and Operating Agency approval. Home modification expenditures are limited to $5,000 per waiver participant per lifetime unless additional amounts are approved by the Alabama Medicaid Agency; AT/DME is limited to $2,000 per year per waiver recipient up to $10,000 per lifetime.
- Home Modification Services require prior authorization by the Operating Agency and have a $5,000 lifetime cap; amounts over $5,000 require Alabama Medicaid Agency approval.
- Assistive Technology and Durable Medical Equipment require prior authorization and approval by the Operating Agency with a maximum of $2,000 per year and $10,000 per lifetime.
AT/DME require Operating Agency prior authorization and documentation
Assistive Technology and Durable Medical Equipment must be prior authorized and approved by the Operating Agency; the physician’s prescription must be maintained in the case file and the recipient must sign and date an acknowledgment of receipt upon completion.
- AT/DME requires Operating Agency prior authorization and approval.
- Physician order/prescription for AT/DME must be maintained in the case file and recipient must sign/date receipt acknowledgement.
No additional prior authorization requirements specified here
No other services in this excerpt are identified as requiring prior authorization beyond those specified for Home Modification and AT/DME.
EPSDT must be exhausted for recipients under 21
State Plan EPSDT services must be exhausted before any use of waiver services for individuals under age 21; this applies to Assistive Technology/DME and Supervisory Visits as stated.
- EPSDT exhaustion is required prior to waiver use for individuals under 21.
- Referenced specifically for AT/DME (chunk 18) and Supervisory Visits (chunk 21).
Exhaust State Plan home health before waiver skilled nursing
If a recipient meets State Plan home health criteria, the State Plan home health benefit must be utilized and exhausted before waiver skilled nursing services are used; waiver skilled nursing will not duplicate State Plan home health.
- Waiver skilled nursing shall not duplicate mandatory State Plan home health; home health must be exhausted first when criteria are met.
- Skilled nursing must still be documented on the Plan of Care and Service Authorization Form.
Document all waiver services on Plan of Care and Service Authorization Form
All waiver services must be documented on the recipient's Plan of Care and the Service Authorization Form; services not listed are not reimbursable and payments rendered for undocumented services will be recovered.
- Every waiver service (including Home Modification, AT/DME, Skilled Nursing, Pest Control, Supervisory Visits) must appear on the Plan of Care and Service Authorization Form.
- Payments for services not documented on those forms will be recovered.
Physician order and recipient acknowledgement required for AT/DME
AT/DME must be ordered by a physician and the prescription retained in the case file; upon completion the recipient must sign and date a form acknowledging receipt.
- Physician order/prescription for AT/DME must be maintained in the case file.
- Recipient must sign and date a receipt acknowledgement upon completion of the service.
Plan of Care and physician order documentation for listed services
For AT/DME, Skilled Nursing, Pest Control, and Supervisory Visits, the required physician orders and service details must be documented on the recipient's Plan of Care and Service Authorization Form; DME prescriptions must be maintained in the case file.
- AT/DME prescriptions/orders must be in the case file and services documented on the Plan of Care.
- Skilled Nursing, Pest Control, and Supervisory Visits must also be documented on the Plan of Care and Service Authorization Form.
Retain and make records available for five years; auditor access and travel costs
Providers must retain records that fully disclose the extent and cost of services for five years and make them accessible to Alabama Medicaid Agency and appropriate officials; if records are not available in Alabama, the provider will pay auditor travel costs. Failure to provide records may lead to recovery of payments.
- Retention period: five years and accessible for audit.
- If records are outside Alabama, provider pays auditor travel costs.
- Payments exceeding allowable costs will be recovered after audit.
Submit written audit appeal to Director, Provider Audit Division within 30 days
To contest fiscal audit findings, an operating agency must submit a written request specifying the contested findings and basis to the Director, Provider Audit Division within 30 days of the official audit letter; if still adverse, a written fair hearing request must be received within 15 days of the informal conference decision letter.
- Submit written request for informal conference to Director, Provider Audit Division within 30 days of official audit letter, specifying contested findings and basis.
- If informal conference decision is adverse, request fair hearing in writing within 15 days of that decision.
Identify and utilize third-party payers; refund post-payment within 60 days
Providers must document efforts to identify any liable third-party payers (including Medicare) and utilize those sources; third-party payments received after billing Medicaid must be refunded to the Alabama Medicaid Agency within 60 days of receipt of the Medicaid payment.
- Make all reasonable efforts to determine liable third-party sources and utilize them before billing Medicaid.
- If third-party payments are received after billing Medicaid, refund them to Alabama Medicaid within 60 days of receipt of Medicaid payment.
Undocumented services are non‑reimbursable and subject to recoupment
Services not documented on the individual's Plan of Care and Service Authorization Form are not reimbursable; payments rendered for such services will be recovered in accordance with audit and recovery provisions.
- Undocumented services will not be paid and previously paid amounts will be recovered.
- This requirement is reiterated across multiple service sections and applies to all waiver services.
Agency may deny HCBS for health/safety, cost, cooperation, or goals noncompliance
The Alabama Medicaid Agency or its operating agencies may deny HCBS if the individual's health and safety is at risk in the community, if the cost to serve the individual on the waiver exceeds the cost of nursing facility care, if the individual does not cooperate with a provider, or if the individual does not meet waiver goals/objectives.
- Denial may be based on health/safety risk in community, higher cost to serve than nursing facility, lack of cooperation with providers, or failure to meet waiver goals/objectives.
No payment without Plan of Care documentation; recoupment applies
Payments will not be made for services not documented on the Plan of Care and Service Authorization Form; payments rendered for such undocumented services will be recovered.
- This applies specifically to Skilled Nursing and other waiver services as stated in their sections.
- Recovery of payments follows audit and financial accountability provisions.
Pest control limited to one lifetime series; extra treatments require State approval
Pest Control Services are limited to one series of treatments per lifetime; additional treatments may be approved only if lack of treatment would jeopardize the participant’s ability to live in the community and will prompt a State evaluation of the living situation.
- One series per lifetime is standard; excludes lodging, preparatory housework, and replacement of household items.
- Additional treatments require State evaluation and approval based on risk to community living.
Maintain confidentiality; disclosure only with proper consent or subpoena
Providers shall not use or disclose recipient information except with the recipient's written consent, that of their attorney/guardian, upon subpoena, or to duly authorized federal or state representatives; unauthorized disclosure may violate confidentiality rules.
- Confidentiality allowed only with written consent, attorney/guardian consent, subpoena, or to authorized federal/state representatives.
- Unauthorized disclosure is prohibited.
Third‑party liability: pursue payers and refund within 60 days to avoid recoupment
Providers must make reasonable efforts to determine if a third party is liable (including Medicare) and utilize that payer; failure to seek and utilize a liable third-party payer or to refund third-party payments to Medicaid within 60 days may result in liability or recoupment.
- Document efforts to identify liable third-party sources and use them before billing Medicaid.
- Refund third-party payments received after Medicaid billing within 60 days to the Alabama Medicaid Agency to avoid liability.
Program purpose and scope
The waiver provides home‑ and community‑based services to categorically needy individuals who would otherwise require nursing facility care, with the purpose of protecting health, safety, and dignity while reducing institutional expenditures. Services are intended to maintain or improve functioning so the person can remain in the community; all waiver services must be documented on the recipient's Plan of Care and Service Authorization Form and are delivered in compliance with HCBS settings requirements.
Key definitions
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