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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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22-6-224
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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22-6-153
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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22-6-227
Section 22-6-227 Quality assurance committee; reporting requirements. (a) The Medicaid
Agency shall create a quality assurance committee appointed by the Medicaid Commissioner to
review the care rendered through the integrated care networks. The members of the committee
shall serve two-year terms. The Medicaid Agency shall promulgate a rule establishing the membership
and criteria to serve on the quality assurance committee. (b) The Medicaid Agency shall continuously
evaluate the outcome and quality measures adopted by the committee pursuant to this section.
(c) The Medicaid Agency shall utilize available data systems for reporting outcome and quality
measures adopted by the committee and take actions to eliminate any redundant reporting or
reporting of limited value. (d) The Medicaid Agency shall publish the information collected
under this section at aggregate levels that do not disclose information otherwise protected
by law. The information published shall report all of the...
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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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22-6-233
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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22-6-232
Section 22-6-232 Coverage of Medicaid beneficiaries by integrated care networks. (a)
The Medicaid Agency shall determine by rule which groups of Medicaid beneficiaries to include
for coverage by an integrated care network. The Medicaid Agency, without the approval of the
Governor, shall not make a coverage decision that would affect Medicaid beneficiaries who
are directly served by another state agency. (b) Notwithstanding subsection (a), the current
Medicaid long-term care programs shall continue as currently administered by the Medicaid
Agency until one or more integrated care networks are fully operational and has entered into
a risk contract as provided herein. (Act 2015-322, §14.)...
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22-6-231
Section 22-6-231 Implementation of article. (a) The following timeline applies to implementation
of this article: (1) Not later than April 1, 2017, the Medicaid Agency shall establish integrated
care network rules setting forth solvency, governing board, network, and active supervision
requirements, as well as other requirements of the Medicaid Agency. (2) Not later than April
1, 2018, Medicaid Agency will initiate competitive procurement for the services of integrated
care network or networks. (3) Not later than October 1, 2018, one or more integrated care
networks certified by the Medicaid Agency shall begin to deliver services pursuant to a risk
bearing contract. (Act 2015-322, §13.)...
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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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22-6-223
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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