1. (1) Reimbursement will be made in accordance with Chapter 22, Alabama Medicaid Administrative Code.

2. (2) Each nursing facility shall have a payment rate assigned by Medicaid. The patient's available monthly income minus an amount designated for personal maintenance (and in some cases amounts for needy dependents and health insurance premiums) is first applied against this payment rate and Medicaid then pays the balance.

   1. (a) The nursing facility may bill the resident for services not included in the per diem rate (noncovered charges) as explained in this chapter.
   2. (b) Actual payment to the facility for services rendered is made by the fiscal agent for Medicaid in accordance with the fiscal agent billing manual.

3. (3) Residents with Medicare Part A.

   1. (a) Medicaid may pay the Part A coinsurance for the 21st through the 100th day for Medicare/Medicaid eligible recipients who qualify under Medicare rules for skilled level of care.
   2. (b) An amount equal to that applicable to Medicare Part A coinsurance, but not greater than the facility's Medicaid rate will be paid for the 21st through the 100th day. No payment will be made by Medicaid for nursing care in a nursing facility for the first 20 days of care for recipients qualified under Medicare rules.
   3. (c) Nursing facilities must assure that Medicaid recipients eligible for Medicare Part A benefits first utilize Medicare benefits prior to accepting a Medicare/Medicaid recipient as a Medicaid resident.
   4. (d) Residents who do not agree with adverse decisions regarding level of care determinations by Medicare should contact the Medicare fiscal intermediary.

4. (4) Residents Dually Eligible for Medicare Part A and B for
   Therapy Services.

   1. (a) For residents who are dually eligible for Medicaid and
      Medicare coverage, nursing facilities must first bill
      Medicare Part A and/or Part B for covered therapy services –
      including physical therapy, occupational therapy, and speech-
      language pathology therapy. Medicare coverage must be fully
      utilized so that the therapy charge apportionment is
      accurately captured on the Medicaid cost report.

Author: Monica Abron, Health Systems Director, Program Administration

Statutory Authority: State Plan; Title XIX, Social Security Act; 42 C.F.R. §§442.1, et seq., 431.151, et seq., 481.1, et seq.

Editor’s Note: Rule 560-X-10-.08, Reimbursement and Payment Limitations, was renumbered to Rule 560-X-10-.09 as per certification filed August 11, 2003; effective September 15, 2003.

History: Rule effective October 1, 1982. Emergency rule: Effective July 22, 1988. Amended: Effective October 12, 1988. Emergency rule: Effective October 1, 1990. Amended: Effective February 13, 1991; March 13, 1992. Amended: Filed August 11, 2003; effective September 15, 2003. Amended: Published February 27, 2026; effective April 13, 2026.