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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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22-6-163
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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22-6-220
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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22-6-226
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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22-6-150
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-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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22-6-233
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...
alisondb.legislature.state.al.us/alison/CodeOfAlabama/1975/22-6-233.htm - 6K - Match Info - Similar pages
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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22-6-152
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, ยง3.)...
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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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