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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22-6-162
Section 22-6-162 Case-management services. The Medicaid Agency may contract for case-management
services with an organization that has been granted by the Medicaid Agency a probationary
regional care organization certification. If the agency has contracted with such an organization,
and that organization on or before October 1, 2016, or a later date established by the Medicaid
Agency, has failed to gain full regional care organization certification or has had its probationary
certification terminated, then that organization shall refund half the payments, made by the
Medicaid Agency to the organization for case-management services, paid over the previous 12
months. (Act 2013-261, p. 686, §13; Act 2016-377, §1.)...
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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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22-6-157
Section 22-6-157 Termination of regional care organization certification. (a) The Medicaid
Agency shall establish by rule the procedure for the termination of a regional care organization
certification or probationary regional care organization certification for non-performance
of contractual duty or for failure to meet or maintain benchmarks, standards, or requirements
provided by this article or established by the Medicaid Agency as required by this article.
(b) Termination of a regional care organization certification or probationary certification
shall follow the standard administrative process, with the right to a hearing before a hearing
officer appointed by the Medicaid Agency. (Act 2013-261, p. 686, §8.)...
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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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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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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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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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22-6-152
Section 22-6-152 Medicaid regions. The Medicaid Agency shall establish by rule geographic Medicaid
regions in which a regional care organization or alternate care provider may operate, which
together shall cover the entire state. Each Medicaid region, according to an actuary working
for Medicaid, shall be capable of supporting at least two regional care organizations or alternate
care providers. (Act 2013-261, p. 686, §3.)...
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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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