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40-26B-82
Section 40-26B-82 Effectiveness and cessation. (a) The assessment imposed under this
article shall not take effect or shall cease to be imposed and any moneys remaining in the
Hospital Assessment Account in the Alabama Medicaid Program Trust Fund shall be refunded to
hospitals in proportion to the amounts paid by them if any of the following occur: (1) Expenditures
for hospital inpatient and outpatient services paid for by the Alabama Medicaid Program for
fiscal years 2020, 2021, and 2022, are less than the amount paid during fiscal year 2017.
Reimbursement rates under this article for fiscal years 2020, 2021, and 2022, are less than
the rates approved by CMS in Sections 40-26B-79 and 40-26B-80. (2) The Medicaid Agency makes
changes in its rules that reduce hospital inpatient payment rates, outpatient payment rates,
or adjustment payments, including any cost settlement protocol, that were in effect on September
30, 2019. (3) The inpatient or outpatient hospital access payments required...
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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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22-6-153
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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22-6-150
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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40-26B-26
Section 40-26B-26 Reduction of revenues; reimbursement computations; quality incentive
program. THIS SECTION WAS AMENDED BY ACT 2020-147 IN THE 2020 REGULAR SESSION, EFFECTIVE
MAY 18, 2020. THIS IS NOT IN THE CURRENT CODE SUPPLEMENT. (a) No revenues resulting from the
privilege assessment established by this article and applied to increases in covered services
or reimbursement levels or other enhancements of the Medicaid program shall be subject to
reduction or elimination while the privilege assessment is in effect. (b) Every nursing facility
participating in the Medicaid program in the State of Alabama shall be reimbursed according
to the reimbursement methodology contained in Chapter 560-X-22 of the Alabama Medicaid Agency
Administrative Code (Supp. 12/31/95) on January 31, 1998, which methodology is incorporated
by reference herein, except that the following shall apply: (1) The ceiling for the operating
cost center described in Title 560-X-22-.06 (2)(a) of the Alabama Medicaid...
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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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22-6-156
Section 22-6-156 Contracts with alternate care providers. The Medicaid Agency may contract
with an alternate care provider in a Medicaid region only under the terms of this section:
(1) If a regional care organization failed to provide adequate service pursuant to its contract,
or had its certification terminated, or if the Medicaid Agency could not award a contract
to a regional care organization under the terms of Section 22-6-153, or if no organization
had been awarded a regional care organization certificate by October 1, 2016, or a later date
established by the Medicaid Agency if an extension is determined, in the Medicaid Agency's
sole discretion, to be in the best interest of the state, then the Medicaid Agency shall first
offer a contract, to resume interrupted service or to assume service in the region, under
the conditions of Section 22-6-153 to any other regional care organization that Medicaid
judged would meet its quality criteria. (2) If by October 1, 2014, no...
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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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27-3A-3
Section 27-3A-3 Definitions. As used in this chapter, the following words and phrases
shall have the following meanings: (1) DEPARTMENT. The Alabama Department of Public Health.
(2) ENROLLEE. An individual who has contracted for or who participates in coverage under an
insurance policy, a health maintenance organization contract, a health service corporation
contract, an employee welfare benefit plan, a hospital or medical services plan, or any other
benefit program providing payment, reimbursement, or indemnification for health care costs
for the individual or the eligible dependents of the individual. (3) PROVIDER. A health care
provider duly licensed or certified by the State of Alabama. (4) UTILIZATION REVIEW. A system
for prospective and concurrent review of the necessity and appropriateness in the allocation
of health care resources and services given or proposed to be given to an individual within
this state. The term does not include elective requests for clarification of...
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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...
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