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22-6-163
Section 22-6-163 Legislative findings; rules; collaboration; approval of agreements
and contracts; state action immunity; confidentiality of records; additional duties. (a) The
Legislature declares that collaboration among public payers, private health carriers, third
party purchasers, and providers to identify appropriate service delivery systems and reimbursement
methods in order to align incentives in support of integrated and coordinated health care
delivery is in the best interest of the public. Collaboration pursuant to this article is
to provide quality health care at the lowest possible cost to Alabama citizens who are Medicaid
eligible. The Legislature, therefore, declares that this health care delivery system affirmatively
contemplates the foreseeable displacement of competition, such that any anti-competitive effect
may be attributed to the state's policy to displace competition in the delivery of a coordinated
system of health care for the public benefit. In furtherance of...
alisondb.legislature.state.al.us/alison/CodeOfAlabama/1975/22-6-163.htm - 6K - Match Info - Similar pages
22-6-233
Section 22-6-233 Legislative findings; certification of collaborators; powers of Medicaid
Agency; state action immunity. (a) The Legislature declares that collaboration among public
payers, private health carriers, third party purchasers, and providers to identify appropriate
service delivery systems and reimbursement methods in order to align incentives in support
of integrated and coordinated health care delivery is in the best interest of the public.
Collaboration pursuant to this article is to provide quality health care at the lowest possible
cost to Alabama citizens who are Medicaid eligible. The Legislature, therefore, declares that
this health care delivery system affirmatively contemplates the foreseeable displacement of
competition, such that any anti-competitive effect may be attributed to the state's policy
to displace competition in the delivery of a coordinated system of health care for the public
benefit. In furtherance of this goal, the Legislature declares its intent...
alisondb.legislature.state.al.us/alison/CodeOfAlabama/1975/22-6-233.htm - 6K - Match Info - Similar pages
22-6-220
Section 22-6-220 Definitions. For the purposes of this article, the following words
shall have the following meanings: (1) CAPITATION PAYMENT. A payment the state Medicaid Agency
makes periodically to the integrated care network on behalf of each recipient enrolled under
a contract for the provision of medical services pursuant to this article. (2) COLLABORATOR.
A private health carrier, third party purchaser, provider, health care center, health care
facility, state and local governmental entity, or other public payers, corporations, individuals,
and consumers who are expecting to collectively cooperate, negotiate, or contract with another
collaborator, or integrated care network in the health care system. (3) INTEGRATED CARE NETWORK.
One or more statewide organizations of health care providers, with offices in each regional
care organization region, that contracts with the Medicaid Agency to provide Medicaid benefits
to certain Medicaid beneficiaries as defined in subdivision (4) and...
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22-6-150
Section 22-6-150 Definitions. For the purposes of this article, the following words
shall have the following meanings: (1) ALTERNATE CARE PROVIDER. A contractor, other than a
regional care organization, that agrees to provide a comprehensive package of Medicaid benefits
to Medicaid beneficiaries in a defined region of the state pursuant to a risk contract. (2)
CAPITATION PAYMENT. A payment the state Medicaid Agency makes periodically to a contractor
on behalf of each recipient enrolled under a contract for the provision of medical services.
(3) CARE DELIVERY SYSTEM. The manner in which the benefits and services set forth in the state
Medicaid plan are provided to Medicaid beneficiaries. (4) COLLABORATOR. A private health carrier,
third party purchaser, provider, health care center, health care facility, state and local
governmental entity, or other public payers, corporations, individuals, and consumers who
are expecting to collectively cooperate, negotiate, or contract with another...
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22-6-153
Section 22-6-153 Contract to provide medical care to Medicaid beneficiaries; enrollment;
grievance procedures; duties of Medicaid Agency. (a) Subject to approval of the federal Centers
for Medicare and Medicaid Services, the Medicaid Agency shall enter into a contract in each
Medicaid region for at least one fully certified regional care organization to provide, pursuant
to a risk contract under which the Medicaid Agency makes a capitated payment, medical care
to Medicaid beneficiaries. However, 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. The Medicaid Agency may contract with more than one regional care organization in
a Medicaid region. Pursuant to the contract, the Medicaid Agency shall set capitation payments
for the regional care organization. (b) The Medicaid Agency shall...
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22-6-151
Section 22-6-151 Regional care organizations; governing board of directors; citizen's
advisory committee; solvency and financial requirements; reporting; provider standards committee.
(a) A regional care organization shall serve only Medicaid beneficiaries in providing medical
care and services. (b) Notwithstanding any other provision of law, a regional care organization
shall not be deemed an insurance company under state law. (c)(1) A regional care organization
and an organization with probationary regional care organization certification shall have
a governing board of directors composed of the following members: a. Twelve members shall
be persons representing risk-bearing participants in the regional care organization or organization
with probationary certification. A participant bears risk by contributing cash, capital, or
other assets to the regional care organization. A participant also bears risk by contracting
with the regional care organization to treat Medicaid beneficiaries...
alisondb.legislature.state.al.us/alison/CodeOfAlabama/1975/22-6-151.htm - 9K - Match Info - Similar pages
22-6-154
Section 22-6-154 Quality assurance committee; collection and publication of information.
(a) The Medicaid Agency shall create a quality assurance committee appointed by the Medicaid
Commissioner. The members of the committee shall serve two-year terms. At least 60 percent
of the members shall be physicians who provide care to Medicaid beneficiaries served by a
regional care organization. In making appointments to the committee, the Medicaid Commissioner
shall seek input from the appropriate professional associations. (b) The committee shall identify
objective outcome and quality measures, including measures of outcome and quality for ambulatory
care, inpatient care, chemical dependency and mental health treatment, oral health care, and
all other health services provided by coordinated care organizations. Quality measures adopted
by the committee shall be consistent with existing state and national quality measures. The
Medicaid Commissioner shall incorporate these measures into...
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40-26B-70
Section 40-26B-70 Definitions. For purposes of this article, the following terms shall
have the following meanings: (1) ACCESS PAYMENT. A payment by the Medicaid program to an eligible
hospital for inpatient or outpatient hospital care, or both, provided to a Medicaid recipient.
(2) ALL PATIENT REFINED DIAGNOSIS-RELATED GROUP (APR-DRG). A statistical system of classifying
any non-Medicare inpatient stay into groups for the purposes of payment. (3) ALTERNATE CARE
PROVIDER. A contractor, other than a regional care organization, that agrees to provide a
comprehensive package of Medicaid benefits to Medicaid beneficiaries in a defined region of
the state pursuant to a risk contract. (4) CERTIFIED PUBLIC EXPENDITURE (CPE). A certification
in writing of the cost of providing medical care to Medicaid beneficiaries by publicly owned
hospitals and hospitals owned by a state agency or a state university plus the amount of uncompensated
care provided by publicly owned hospitals and hospitals...
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22-6-221
Section 22-6-221 Service by integrated care network; board of directors. (a) An integrated
care network shall serve only Medicaid beneficiaries in providing medical care and services.
For the purposes of this article, a beneficiary cannot be a member of both an integrated care
network and a regional care organization. (b) An integrated care network shall provide required
medical care and services to Medicaid beneficiaries and may coordinate care provided by or
through an affiliation of other health care providers or other programs as the Medicaid Agency
shall determine. (c) Notwithstanding any other provision of law, the integrated care network
shall not be deemed an insurance company under state law. (d)(1) An integrated care network
shall have a governing board of directors composed of the following members: a. Twelve members
shall be persons representing risk bearing participants. A participant bears risk by contributing
cash, capital, or other assets to the integrated care network....
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27-14-11.1
Section 27-14-11.1 Contents of policies - Denial or reduction of benefits due to Medicaid
eligibility void. (a) For purposes of this section, "private insurer" is
defined as any of the following: (1) Any commercial insurance company offering health or casualty
insurance to individuals or groups, including both experience-rated contracts and indemnity
contracts. (2) Any profit or nonprofit prepaid plan offering either medical services or full
or partial payment for the diagnosis or treatment of an injury, disease, or disability. (3)
Any organization administering health or casualty insurance plans for professional associations,
unions, fraternal groups, employer-employee benefit plans, and any similar organization offering
these payments or services, including self-insured and self-funded plans. (4) Any health insurer,
including group health plans, as defined in Section 607(1) of the Employee Retirement
Income Security Act of 1974, self-insured plans, service benefit plans, managed care...
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