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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22-6-153
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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22-6-226
Section 22-6-226 Review and approval of contracts; rules governing operation of integrated care networks. (a) All provider contracts of an organization granted final certification as an integrated care network shall be subject to review and approval of the Medicaid Agency. (b)(1) If a provider is dissatisfied with any term or provision of the agreement or contract offered by an integrated care network, the provider shall: a. Seek redress with the integrated care network. In providing redress, an integrated care network shall afford the provider a review by a panel composed of a representative of an integrated care network, the same type of provider, and a representative of the citizens' advisory board appointed by the chair of the advisory board. b. After seeking redress with an integrated care network, a provider or an integrated care network who remains dissatisfied may request a review of such disputed term or provision by the Medicaid Agency. The Medicaid Agency shall have 10 days...
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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...
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22-6-229
Section 22-6-229 Termination of certification. (a) The Medicaid Agency shall establish by rule the procedure for the termination of an integrated care network certification for non-performance of contractual duty or for failure to meet or maintain standards or requirements provided by this article or established by the Medicaid Agency as required by this article. (b) Termination of an integrated care network certification shall follow the standard administrative process with the right to a hearing before a hearing officer appointed by the Medicaid Agency. (Act 2015-322, §11.)...
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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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22-6-221
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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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...
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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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22-6-228
Section 22-6-228 Risk contracts. A risk contract between the Medicaid Agency and an integrated care network shall be for two years, with the option for Medicaid to renew the contract for not more than three additional one-year periods. The Medicaid Agency shall obtain provider input and an independent evaluation of the cost savings, patient outcomes, and quality of care provided by an integrated care network, and obtain the results of an integrated care network's evaluation in time to use the findings to decide whether to enter into another multi-year contract with the integrated care networks or change the Medicaid care delivery system associated with an integrated care network. (Act 2015-322, §10.)...
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