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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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22-6-230
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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40-26B-83
Section 40-26B-83 State plan amendment. (a) There is established the Hospital Services and
Reimbursement Panel to advise in the development of and approve any state plan amendment which
involves hospital services or reimbursement to be submitted to the Centers for Medicare and
Medicaid Services. (1) The panel shall consist of six members and be constituted in the following
manner: a. The Commissioner of the Alabama Medicaid Agency. b. Three members to be appointed
by the Governor from a list of 10 names submitted by the Alabama Hospital Association. The
hospital members appointed shall represent the diverse ownership type of hospitals in the
state. c. Two members to be appointed by the Governor. (2) All panel members shall be residents
of Alabama and the composition of the board shall reflect the racial, gender, geographic,
urban/rural, and economic diversity of the state. The panel shall meet within 30 days subsequent
to May 15, 2009, to elect a chair and establish procedures...
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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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27-1-19
Section 27-1-19 Reimbursement of health care providers. (a) The insured, or health or dental
plan beneficiary may assign reimbursement for health or dental care services directly to the
provider of services. Health benefits include medical, pharmacy, podiatric, chiropractic,
optometric, durable medical equipment, and home care services. The company or agency, when
authorized by the insured, or health or dental plan beneficiary, shall pay directly to the
health care provider the amount of the claim, under the same criteria and payment schedule
that would have been reimbursed directly to the contract provider, and any applicable interest.
This amount only applies to assigned claims. Any company or agency making a payment to the
insured, or health or dental plan beneficiary, after the rights of reimbursement have been
assigned to the provider of services, shall be liable to the provider for the payment. If
the company or agency fails to reimburse the provider in accordance with the terms...
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27-26-5
Section 27-26-5 Reports of judgments and settlements; confidentiality; penalty. (a) Any insurance
company which sells medical liability insurance to Alabama physicians or their professional
corporations or professional associations, or to hospitals or other health care providers
shall be required to report to the state licensing agency which issues the license of the
physician, hospital, or other health care provider any final judgment or any settlement in
or out of court resulting from a claim or action for damages for personal injuries caused
by an error, omission, or negligence in the performance of professional services with or without
consent rendered by its policyholder within 30 days after entry of a judgment in court or
agreement to settle a claim in or out of court. (b) The report rendered to the appropriate
state agency shall consist of the name of the policyholder, or if the policyholder is a professional
corporation or professional association, the name of the physician or...
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35-11-371
Section 35-11-371 Perfection of lien. (a) For the purposes of this section, the following terms
shall have the following meanings: (1) HEALTH CARE PAYOR. A health care insurer, health maintenance
organization, or health care service plan organized under Article 6, Chapter 20, Title 10A,
authorized to provide health care coverage in the state. (2) SATISFY THE CLAIM. Receipt by
the hospital of either of the following: a. Full payment for services as billed. b. If the
hospital has a contract with the injured person's health care payor, payment together with
all credits, discounts, and contractual adjustments that the patient's bill would be entitled
under the contract, including recoupments, between the hospital and the patient's health care
payor which extinguish the patient's obligation for the services rendered. (b) Unless specifically
contrary to any contractual agreement between the hospital and the injured person's health
care payor or unless contrary to any statute or governmental...
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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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40-26B-6
Section 40-26B-6 Use of revenues; reimbursement. (a) The Alabama Medicaid Agency shall use
the revenues from the tax levied by this article in furtherance of the purposes of this article,
provided that any such uses shall be limited to those for which federal financial participation
under Title XIX of the Social Security Act is available. (b) Any reimbursement due a pharmaceutical
provider under the Medicaid Program shall be paid in a timely fashion. If the amount payable
is not in dispute and is not paid by the Alabama Medicaid Agency within 30 days of the due
date, interest on the amount due shall be charged. The interest shall be the legal amount
currently charged by the state. (Acts 1991, No. 91-124, p. 148, ยง5.)...
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40-26B-81
Section 40-26B-81 Medicaid hospital access payments. (a) If the Medicaid Agency begins making
payments pursuant to Article 9 of Chapter 6 of Title 22, on or before September 30, 2019,
to preserve and improve access to hospital services, for hospital inpatient and outpatient
services rendered on or after October 1, 2018, the agency shall consider the published inpatient
and outpatient rates as defined in Sections 40-26B-79 and 40-26B-80 as the minimum payment
allowed. (b) If the Medicaid Agency does not begin making payments pursuant to Article 9 of
Chapter 6 of Title 22, on or before September 30, 2019, the aggregate hospital access payment
amount is an amount equal to the upper payment limit, less total hospital base payments determined
under this article. All publicly, state-owned, and privately operated hospitals shall be eligible
for inpatient and outpatient hospital access payments for fiscal years 2020, 2021, and 2022,
as set forth in this article. (1) In addition to any other...
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