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22-6-224
Section 22-6-224 Medicaid Agency to contract for medical care; enrollment; delivery of services;
reimbursement. (a) Subject to approval of the federal Centers for Medicare and Medicaid Services,
the Medicaid Agency shall enter into contracts with one or more integrated care networks to
provide, pursuant to a risk contract under which the Medicaid Agency makes a capitated payment,
medical care to Medicaid beneficiaries assigned to the integrated care network. The Medicaid
Agency may enter into a contract pursuant to this section only if, in the judgment of the
Medicaid Agency, care of Medicaid beneficiaries would be better, more efficient, and less
costly than under the then existing care delivery system. Pursuant to the contract, the Medicaid
Agency shall set capitation payments for the integrated care network. (b) The Medicaid Agency
shall enroll beneficiaries it designates into an integrated care network consistent with guidance
from the Center for Medicare and Medicaid Services. (c)...
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22-6-225
Section 22-6-225 Denial of claims; grievances and appeals. (a) The Medicaid Agency shall establish
by rule procedures for safeguarding against wrongful denial of claims and addressing grievances
of enrollees in an integrated care network. (b) If a patient or the provider is dissatisfied
with the decision of an integrated care network, the patient or provider may file a written
notice of appeal to the Medicaid Agency. The Medicaid Agency shall adopt rules governing the
appeal, which shall include a full evidentiary hearing and a finding on the record. The Medicaid
Agency's decision shall be binding upon the integrated care network. However, a patient or
provider may file an appeal in circuit court in the county in which the patient resides, or
the county in which the provider provides services. (c) The Medicaid Agency shall by rule
establish procedures for addressing grievances and appeals of the integrated care network.
The appeal procedure shall include an opportunity for a fair...
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22-6-158
Section 22-6-158 Contracts with service providers. A regional care organization shall contract
with any willing hospital, doctor, or other provider to provide services in a Medicaid region
if the provider is willing to accept the payments and terms offered comparable providers.
Any provider shall meet licensing requirements set by law, shall have a Medicaid provider
number, and shall not otherwise be disqualified from participating in Medicare or Medicaid.
(Act 2013-261, p. 686, §9.)...
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22-6-223
Section 22-6-223 Solvency and financial requirements. (a) An integrated care network shall
meet minimum solvency and financial requirements as provided by the Medicaid Agency. The Medicaid
Agency shall require the integrated care network, as a condition of certification or continued
certification, to maintain minimum solvency and financial reserves. The Medicaid Agency shall
hereafter promulgate rules setting forth requirements for minimum solvency, financial reserves,
and other financial requirements of an integrated care network based on the number of integrated
care networks that may be certified and based on actuarial soundness as determined by the
Medicaid Agency. The Medicaid Agency shall allow for the requirements to be met through the
submission of an irrevocable letter of credit in an amount equal to the financial reserves
that would otherwise be required of the integrated care network, to guarantee the performance
of the provisions of the risk contract. If an irrevocable...
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22-6-161
Section 22-6-161 Evaluation and report on dental care program for Medicaid beneficiaries. (a)
The Medicaid Agency, with input from dental care providers, shall conduct an evaluation of
the existing dental care program for Medicaid beneficiaries and, on October 1, 2015, shall
report the findings of the evaluation to the Legislature and Governor. (b) Notwithstanding
the above, the current Medicaid dental care programs shall continue as currently administered
by the Medicaid Agency until the end of the fiscal year when the evaluation required in subsection
(a) is reported to the Legislature and the Governor. (Act 2013-261, p. 686, §12.)...
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22-6-222
Section 22-6-222 Citizens' advisory committee. There shall be a citizens' advisory committee
constituted to advise the integrated care network on ways the integrated care network may
be more efficient in providing quality care to Medicaid beneficiaries. In addition, the advisory
committee shall carry out other functions and duties assigned to it by the integrated care
network and approved by the Medicaid Agency. The committee shall meet all of the following
criteria: (1) Be selected in a method established by the organization seeking to become an
integrated care network, or established by an integrated care network, and approved by the
Medicaid Agency. (2) At least 20 percent of its members shall be Medicaid beneficiaries or
sponsors of Medicaid beneficiaries or, if the organization has been certified as an integrated
care network, at least 20 percent of its members shall be Medicaid beneficiaries enrolled
in the integrated care network, or their sponsor. (3) Include members who are...
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22-6-230
Section 22-6-230 Rates for contracting services; provider requirements. An integrated care
network shall contract with any willing nursing home, doctor, home and community waiver program,
or other provider to provide services through an integrated care network if the provider is
willing to accept the payments and terms offered comparable providers, where applicable, but
in no event less than amounts historically paid by the Medicaid Agency to comparable providers.
To the extent that the Medicaid Agency currently calculates and establishes provider-specific
rates for any provider category on an annualized basis, it shall continue to calculate and
establish such rates and the integrated care network shall be required to offer providers
from that category not less than their established rates. Any provider shall meet licensing
requirements set by law, shall have a Medicaid provider number, and shall not otherwise be
disqualified from participating in Medicare or Medicaid. (Act 2015-322,...
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27-1-17.1
Section 27-1-17.1 Payment of providers through electronic funds transfer methods. (a) As used
in this section, the following words shall have the following meanings: (1) ACH ELECTRONIC
FUNDS TRANSFER. An electronic funds transfer through the Health Insurance Portability and
Accountability Act (HIPPA) standard Automated Clearing House network. (2) COVERED HEALTH CARE
PROVIDER. A physician as defined in Section 34-24-50.1; a dentist as defined in Section 34-9-1;
a chiropractor as defined in Section 34-24-120; an individual engaged in the practice of optometry
as defined in Section 34-22-1; other licensed health care professionals as defined in Title
34; a hospital as defined in Section 22-21-20; and a health care facility, or other provider
who or that is accredited, licensed, or certified and who or that is performing within the
scope of that accreditation, license, or certification. (3) HEALTH INSURANCE PLAN. Any hospital
and medical expense incurred policy, health maintenance...
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40-26B-73
Section 40-26B-73 Hospital Assessment Account. (a)(1) There is created within the Health Care
Trust Fund referenced in Article 3 of Chapter 6 of Title 22 of a designated account known
as the Hospital Assessment Account. (2) The hospital assessments imposed under this article
shall be deposited into the Hospital Assessment Account. (3) If the Medicaid Agency begins
making payments under Article 9 of Chapter 6 of Title 22, while Act 2017-382 is in force,
the hospital intergovernmental transfers imposed under this article shall be deposited into
the Hospital Assessment Account. (b) Moneys in the Hospital Assessment Account shall consist
of: (1) All moneys collected or received by the department from privately operated hospital
assessments imposed under this article; (2) Any interest or penalties levied in conjunction
with the administration of this article; and (3) Any appropriations, transfers, donations,
gifts, or moneys from other sources, as applicable; and (4) If the Medicaid Agency...
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22-5C-2
Section 22-5C-2 State Advisory Council on Palliative Care and Quality of Life. (a) Not later
than November 23, 2015, the State Health Department shall establish a State Advisory Council
on Palliative Care and Quality of Life within the department. (b) The council membership shall
be appointed by the State Health Officer and shall include interdisciplinary palliative care
medical, nursing, social work, pharmacy, and spiritual professional expertise; patient and
family caregiver advocate representation, and any other relevant appointees the State Health
Officer determines appropriate. The State Health Officer shall consider the racial, gender,
geographic, urban/rural, and economic diversity of the state when appointing members. Membership
shall specifically include health professionals having palliative care work experience or
expertise in palliative care delivery models in a variety of inpatient, outpatient, and community
settings such as acute care, long-term care, and hospice and with...
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