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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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22-6-160
Section 22-6-160 Evaluation and report on long-term care system for Medicaid beneficiaries.
The Medicaid Agency shall decide which groups of Medicaid beneficiaries to include for coverage
by a regional care organization or alternate care provider. 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. (Act 2013-261, p. 686, §11; Act 2015-322,
§1.)...
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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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22-6-154
Section 22-6-154 Quality assurance committee; collection and publication of information. (a)
The Medicaid Agency shall create a quality assurance committee appointed by the Medicaid Commissioner.
The members of the committee shall serve two-year terms. At least 60 percent of the members
shall be physicians who provide care to Medicaid beneficiaries served by a regional care organization.
In making appointments to the committee, the Medicaid Commissioner shall seek input from the
appropriate professional associations. (b) The committee shall identify objective outcome
and quality measures, including measures of outcome and quality for ambulatory care, inpatient
care, chemical dependency and mental health treatment, oral health care, and all other health
services provided by coordinated care organizations. Quality measures adopted by the committee
shall be consistent with existing state and national quality measures. The Medicaid Commissioner
shall incorporate these measures into...
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22-6-200
Section 22-6-200 Federal financial participation; contract for services. This article shall
be of no effect if federal financial participation under Title XIX of the Social Security
Act is not available to the Medicaid program for the purposes of this article at the approved
federal medical assistance percentage, established under Section 1905 of the Social Security
Act, for the applicable fiscal year, or in the event a contract for services between the PACE
program and the State of Alabama Medicaid Agency or Regional Care Organization is not executed
by September 30, 2014, and by the end of each subsequent state fiscal year thereafter. (Act
2014-126, p. 236, §11.)...
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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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22-6-227
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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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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22-6-225
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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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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