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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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22-6-153
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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22-6-224
Section 22-6-224 Medicaid Agency to contract for medical care; enrollment; delivery of services;
reimbursement. (a) Subject to approval of the federal Centers for Medicare and Medicaid Services,
the Medicaid Agency shall enter into contracts with one or more integrated care networks to
provide, pursuant to a risk contract under which the Medicaid Agency makes a capitated payment,
medical care to Medicaid beneficiaries assigned to the integrated care network. 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. Pursuant to the contract, the Medicaid
Agency shall set capitation payments for the integrated care network. (b) The Medicaid Agency
shall enroll beneficiaries it designates into an integrated care network consistent with guidance
from the Center for Medicare and Medicaid Services. (c)...
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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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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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22-6-230
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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22-6-223
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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22-6-233
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...
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22-6-222
Section 22-6-222 Citizens' advisory committee. There shall be a citizens' advisory committee
constituted to advise the integrated care network on ways the integrated care network may
be more efficient in providing quality care to Medicaid beneficiaries. In addition, the advisory
committee shall carry out other functions and duties assigned to it by the integrated care
network and approved by the Medicaid Agency. The committee shall meet all of the following
criteria: (1) Be selected in a method established by the organization seeking to become an
integrated care network, or established by an integrated care network, and approved by the
Medicaid Agency. (2) At least 20 percent of its members shall be Medicaid beneficiaries or
sponsors of Medicaid beneficiaries or, if the organization has been certified as an integrated
care network, at least 20 percent of its members shall be Medicaid beneficiaries enrolled
in the integrated care network, or their sponsor. (3) Include members who are...
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