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    v1.0.28
    OpenPayerPolicy UpdatesClinical/Medical PolicyAlabama Medicaid Ventilator/Tracheostomy Coverage …
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    CurrentAlabama MedicaidPolicy N/A

    Ventilator-Dependent and Qualified Tracheostomy Care

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    Rules governing Alabama Medicaid supplemental payment, facility enrollment, staffing, and clinical criteria for nursing facilities that provide care to ventilator-dependent and/or qualified tracheostomy Medicaid residents.

    Policy Summary
    PayerAlabama Medicaid
    PolicyVentilator-Dependent and Qualified Tracheostomy Care
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateJan 16, 2012
    Last ReviewJan 16, 2012
    Next Review DateN/A
    Key ActionObtain written prior approval from Alabama Medicaid and complete provider enrollment before any supplemental reimbursement is granted.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    120 USDsupplemental daily fee-for-service payment (indexed annually)
    24 hoursrequired RN/LPN availability
    12 monthsapproval interval for supplemental payments
    14 daysnotify Medicaid after weaning

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Coverage Criteria for Ventilator-Dependent and Qualified Tracheostomy Residents

    inv-01: Admission — Ventilator-Dependent

    Covered when ALL of the following are met

    Ventilator-dependent admission criteria: (a) Resident is not able to breathe without a volume ventilator with a backup; (b) resident uses the ventilator seven days per week; (c) resident has a tracheostomy; (d) resident requires daily respiratory therapy intervention (oxygen therapy, tracheostomy care, chest physiotherapy, or deep suctioning) with these services available 24 hours a day; (e) resident is medically stable and does not require acute care services; and a Registered Nurse or Licensed Practical Nurse must be readily available and have primary responsibility of the unit at all times.all conditions required

    Residents who met the above at admission but are in the process of being weaned remain classified as ventilator-dependent until weaning is completed. This excludes residents who are only on C-PAP or Bi-PAP devices.

    inv-02: Admission — Qualified Tracheostomy

    Covered when ALL of the following are met

    Qualified tracheostomy admission criteria: (a) Resident is not able to breathe without the use of a tracheostomy; (b) resident requires daily respiratory therapy intervention (oxygen therapy, tracheostomy care, chest physiotherapy, or deep suctioning) with these services available 24 hours a day; (c) resident is medically stable and does not require acute care services; (d) a Registered Nurse or Licensed Practical Nurse must be readily available and have primary responsibility of the unit at all times.all conditions required

    Excludes residents who require only PRN monitoring or suctioning.

    inv-03: Reimbursement Authorization Criteria

    Covered when ALL of the following are met

    Reimbursement and approval: Facility and resident must meet the chapter requirements and prior authorization must be issued by the Alabama Medicaid Agency in writing before any additional reimbursement is allowed; requests must include pertinent sections of the current Minimum Data Set (e.g., Section I, Section J, Section O) and attending physician documentation of the resident's medical condition; the supplemental fee-for-service payment is approved for 12-month intervals.all conditions required

    The nursing facility daily per diem continues per Chapter 22; the supplemental fee-for-service payment amount is indexed annually (listed as $120 and indexed). No additional amount above the current nursing facility rate will be allowed until both resident and facility requirements are met and prior authorization is issued.

    Coverage excludes residents who are not ventilator-dependent because they use only non-invasive positive pressure devices. Specifically, residents who are only on C-PAP or Bi-PAP devices are not considered ventilator-dependent. Likewise, residents who receive only intermittent care such as PRN monitoring or suctioning do not meet the criteria for a qualified tracheostomy resident. These exclusions reflect the rule that ventilator-dependent and qualified tracheostomy status requires continuous need for mechanical ventilation or daily respiratory therapy interventions available 24 hours a day and an RN or LPN readily available with primary responsibility for the unit.

    Alabama Medicaid will not reimburse facilities for modifications to the building or physical plant made solely to enable provision of ventilator-dependent or qualified tracheostomy services. Any capital alterations required to accommodate these residents are the facility's responsibility; the Agency explicitly states it will not pay for changes to the physical plant to provide such services.

    Residents who are not medically stable and require acute care services do not meet the admission criteria for ventilator-dependent or qualified tracheostomy coverage. The policy requires that candidates be medically stable and not in need of acute care; failure to meet this stability requirement excludes the resident from classification and associated supplemental reimbursement.

    Provider Requirements, Prior Authorization, and Enrollment

    Prior Authorization

    Obtain written prior approval and complete enrollment

    Prior approval from Alabama Medicaid must be obtained in writing before any additional reimbursement is allowed; the facility must execute an Addendum to the current Nursing Facility Provider Agreement and complete Medicaid enrollment to designate beds for ventilator-dependent and/or qualified tracheostomy residents.

    • Execute an Addendum to the current Nursing Facility Provider Agreement with the Alabama Medicaid Agency.
    • Complete a Medicaid enrollment application specifying the number of beds designated for ventilator-dependent and/or qualified tracheostomy residents.
    Step Therapy

    Maintain resident classification during weaning

    A resident who is in the process of being weaned from ventilator dependence or qualified tracheostomy treatment continues to be considered a qualified resident until the weaning process is completed.

    • Do not change classification or reimbursement status until the weaning process is complete.

    Key Definitions

    Ventilator-Dependent Resident — definition, monitoring and care requirements
    DefinitionA ventilator-dependent resident is a person on mechanical ventilation necessary to sustain life who requires care and monitoring by a Registered Nurse (RN) or Licensed Practical Nurse (LPN) 24 hours a day and routine interventions by a duly licensed respiratory therapist.
    Ventilator use requirementsResident is not able to breathe without a volume ventilator with a backup and uses the ventilator seven days per week; resident must have a tracheostomy.
    Care and monitoringAn RN or LPN must be readily available and have primary responsibility for the unit at all times; routine respiratory therapist interventions (oxygen therapy, tracheostomy care, chest physiotherapy, deep suctioning) must be available 24 hours a day.
    Medical stabilityResident must be medically stable and not require acute care services to meet admission criteria.
    Weaning statusResidents being weaned who meet admission criteria remain classified as ventilator-dependent until the weaning process is completed.

    Background and Clinical Context

    Ventilator-dependent residents are those who cannot breathe without a volume ventilator with a backup, use the ventilator seven days per week, and have a tracheostomy. These residents require daily respiratory therapy interventions (for example, oxygen therapy, tracheostomy care, chest physiotherapy, or deep suctioning) that must be available 24 hours a day. An RN or LPN must be readily available and have primary responsibility for the unit at all times. Residents meeting these criteria but in the process of being weaned remain classified as ventilator-dependent until weaning is complete; this classification explicitly excludes those only on C-PAP or Bi-PAP devices.

    Policy Summary
    PayerAlabama Medicaid
    PolicyVentilator-Dependent and Qualified Tracheostomy Care
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateJan 16, 2012
    Last ReviewJan 16, 2012
    Next Review DateN/A
    Key ActionObtain written prior approval from Alabama Medicaid and complete provider enrollment before any supplemental reimbursement is granted.
    SourceLink
    On This Page
    Coverage Criteria for Ventilator-Dependent and Qualified Tracheostomy ResidentsProvider Requirements, Prior Authorization, and EnrollmentKey DefinitionsBackground and Clinical Context
  1. Notify Medicaid per applicable rules once weaning is finalized (see notification timelines elsewhere in the chapter).
    2. Documentation Required

    Include required MDS sections and physician documentation with prior approval

    Requests for additional reimbursement must be submitted in writing and include the pertinent sections of the most current Minimum Data Set (MDS) — at minimum Section I (Active Diagnoses), Section J (Health Conditions), and Section O (Special Treatments, Procedures, and Programs) — plus attending physician documentation of the resident's medical condition.

    • Submit written prior approval request to the Alabama Medicaid Agency.
    • Attach MDS sections: Section I, Section J, and Section O.
    • Include attending physician documentation describing the resident's medical condition.
    Denial Risk

    Facility participation may be limited or denied under specified conditions

    Participation may be limited or denied if the nursing facility's Medicaid certification termination is imminent, the facility is a Special Focus Facility under review, or the facility does not meet Department of Public Health and Medicaid requirements to serve these residents.

    • Facilities with imminent Medicaid certification termination may be barred from participation.
    • Special Focus Facilities under review by CMS, the Alabama Department of Public Health, or the Alabama Medicaid Agency may be limited or denied.
    • Facilities that fail to meet established Department of Public Health and Medicaid requirements to serve ventilator-dependent or qualified tracheostomy residents may be denied participation.
    Qualified Tracheostomy Resident — definition, monitoring and care requirements
    DefinitionA qualified tracheostomy resident is a person who has a tracheostomy, receives oxygen therapy, and requires care and monitoring by a Registered Nurse (RN) or Licensed Practical Nurse (LPN) 24 hours a day and routine interventions by a duly licensed respiratory therapist.
    Breathing requirementResident is not able to breathe without the use of a tracheostomy.
    Care and monitoringAn RN or LPN must be readily available and have primary responsibility for the unit at all times; routine respiratory therapist interventions (oxygen therapy, tracheostomy care, chest physiotherapy, deep suctioning) must be available 24 hours a day.
    ExclusionsDoes not include residents who require only PRN monitoring or suctioning.
    Medical stabilityResident must be medically stable and not require acute care services to meet admission criteria.