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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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22-6-221
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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22-6-220
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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27-1-17
Section 27-1-17 Limitation periods for payment of claims; overdue claims; retroactive denials,
adjustments, etc.; penalties. (a) Each insurer, health service corporation, and health benefit
plan that issues or renews any policy of accident or health insurance providing benefits for
medical or hospital expenses for its insured persons shall pay for services rendered by Alabama
health care providers within 45 calendar days upon receipt of a clean written claim or 30
calendar days upon receipt of a clean electronic claim. If the insurer, health service corporation,
or health benefit plan is denying or pending the claim, the insurer, health service corporation,
or health benefit plan shall, within 45 calendar days for a written claim and 30 calendar
days for an electronic claim, notify the health care provider or certificate holder of the
reason for denying or pending the claim and what, if any, additional information is required
to process the claim. Any undisputed portion of the claim...
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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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22-6-222
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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22-6-226
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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22-6-153
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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22-6-225
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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22-6-161
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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