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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22-6-153
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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22-6-156
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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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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22-6-150
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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22-6-160
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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22-6-155
Section 22-6-155 Terms of contracts; cost evaluations. An initial contract between the Medicaid Agency and a regional care organization shall be for three years, with the option for the Medicaid Agency to renew the contract for not more than two additional one-year periods. The Medicaid Agency shall obtain provider input and an independent evaluation of the cost savings, patient outcomes, and quality of care provided by each regional care organization, and obtain the results of each regional care organization's evaluation in time to use the findings to decide whether to enter into another multi-year contract with the regional care organization or change the Medicaid region's care-delivery system. (Act 2013-261, p. 686, §6; Act 2014-434, p. 1598, §1.)...
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22-6-158
Section 22-6-158 Contracts with service providers. A regional care organization shall contract with any willing hospital, doctor, or other provider to provide services in a Medicaid region if the provider is willing to accept the payments and terms offered comparable providers. 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 2013-261, p. 686, §9.)...
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