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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22-6-159
Section 22-6-159 Implementation of article. (a) The following is the timeline for implementation of this article: (1) Not later than October 1, 2013, the Medicaid Agency shall establish Medicaid regions. (2) Not later than October 1, 2014, an organization seeking to become a regional care organization shall have established a governing board and structure as approved by the Medicaid Agency. An organization may receive probationary certification as a regional care organization upon submission of an application for, and demonstration of, a governing board acceptable to the Medicaid Agency. Probationary certification shall expire on October 1, 2016, or a later date established by the Medicaid Agency. (3) Not later than April 1, 2015, an organization with probationary regional care organization certification shall have demonstrated to Medicaid's approval the ability to establish an adequate medical service delivery network. (4) Not later than October 1, 2015, an organization with...
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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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22-6-221
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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22-6-229
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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22-6-223
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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22-6-230
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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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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22-6-225
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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22-6-227
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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